- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.32 / $732.30 / $732.30
| Professional | | $727.32 | $732.30 | $732.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.03 / $945.03 / $2,202.36
| Professional | | $945.03 | $945.03 | $2,202.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.08 / $1,076.29 / $1,384.70
| Professional | | $655.08 | $1,076.29 | $1,384.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.32 / $945.36 / $1,384.70
| Professional | | $642.32 | $945.36 | $1,384.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.20 / $869.71 / $2,528.30
| Professional | | $776.20 | $869.71 | $2,528.30 |