- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.25 / $1,095.64 / $1,124.83
| Professional | | $804.25 | $1,095.64 | $1,124.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.66 / $1,401.17 / $3,311.53
| Professional | | $1,188.66 | $1,401.17 | $3,311.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.13 / $1,601.61 / $2,080.50
| Professional | | $1,019.13 | $1,601.61 | $2,080.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.76 / $1,382.18 / $2,080.50
| Professional | | $965.76 | $1,382.18 | $2,080.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.70 / $1,306.73 / $3,798.76
| Professional | | $1,171.70 | $1,306.73 | $3,798.76 |