- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.83 / $856.83 / $911.18
| Professional | | $856.83 | $856.83 | $911.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.34 / $1,294.71 / $2,769.47
| Professional | | $1,098.34 | $1,294.71 | $2,769.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.14 / $1,213.10 / $1,637.43
| Professional | | $820.14 | $1,213.10 | $1,637.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.60 / $1,082.43 / $1,637.43
| Professional | | $750.60 | $1,082.43 | $1,637.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.07 / $1,028.44 / $2,989.75
| Professional | | $885.07 | $1,028.44 | $2,989.75 |