- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.27 / $880.66 / $880.66
| Professional | | $868.27 | $880.66 | $880.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.80 / $1,312.92 / $2,628.68
| Professional | | $1,113.80 | $1,312.92 | $2,628.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.59 / $1,258.71 / $1,641.09
| Professional | | $805.59 | $1,258.71 | $1,641.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.76 / $1,089.48 / $1,641.09
| Professional | | $760.76 | $1,089.48 | $1,641.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.64 / $1,030.74 / $2,996.42
| Professional | | $909.64 | $1,030.74 | $2,996.42 |