- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.31 / $759.31 / $815.68
| Professional | | $759.31 | $759.31 | $815.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.47 / $1,286.58 / $2,493.32
| Professional | | $1,091.47 | $1,286.58 | $2,493.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.23 / $1,080.34 / $1,466.33
| Professional | | $729.23 | $1,080.34 | $1,466.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.66 / $967.24 / $1,466.33
| Professional | | $670.66 | $967.24 | $1,466.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.21 / $920.98 / $2,677.34
| Professional | | $788.21 | $920.98 | $2,677.34 |