- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.65 / $980.65 / $1,035.17
| Professional | | $980.65 | $980.65 | $1,035.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.61 / $1,613.28 / $3,142.22
| Professional | | $1,368.61 | $1,613.28 | $3,142.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.68 / $1,403.24 / $1,876.07
| Professional | | $935.68 | $1,403.24 | $1,876.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.87 / $1,241.41 / $1,876.07
| Professional | | $861.87 | $1,241.41 | $1,876.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.40 / $1,178.33 / $3,425.51
| Professional | | $1,028.40 | $1,178.33 | $3,425.51 |