- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.95 / $1,226.81 / $1,773.01
| Professional | | $973.95 | $1,226.81 | $1,773.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.12 / $1,453.38 / $2,122.96
| Professional | | $741.12 | $1,453.38 | $2,122.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.66 / $1,177.75 / $2,108.16
| Professional | | $873.66 | $1,177.75 | $2,108.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.72 / $1,385.32 / $1,385.32
| Professional | | $1,090.72 | $1,385.32 | $1,385.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.42 / $1,722.14 / $4,846.54
| Professional | | $884.42 | $1,722.14 | $4,846.54 |