- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $2,818.38
| Professional | | $812.83 | $1,148.15 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,348.96 / $1,584.89
| Professional | | $1,348.96 | $1,348.96 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,258.93 / $2,041.74
| Professional | | $724.44 | $1,258.93 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,258.93 / $1,513.56
| Professional | | $954.99 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $2,187.76
| Professional | | $1,071.52 | $1,288.25 | $2,187.76 |