- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.82 / $1,089.08 / $1,101.68
| Professional | | $787.82 | $1,089.08 | $1,101.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.88 / $1,578.25 / $3,292.47
| Professional | | $1,338.88 | $1,578.25 | $3,292.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.36 / $1,575.76 / $2,058.44
| Professional | | $1,011.36 | $1,575.76 | $2,058.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.95 / $1,367.32 / $2,058.44
| Professional | | $954.95 | $1,367.32 | $2,058.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.81 / $1,292.86 / $3,758.47
| Professional | | $1,123.81 | $1,292.86 | $3,758.47 |