- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $637.32 / $895.57 / $915.62
| Professional | | $637.32 | $895.57 | $915.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.00 / $1,603.91 / $2,022.90
| Professional | | $1,223.00 | $1,603.91 | $2,022.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.37 / $1,583.44 / $2,182.71
| Professional | | $902.37 | $1,583.44 | $2,182.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.55 / $1,646.42 / $2,384.79
| Professional | | $945.55 | $1,646.42 | $2,384.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.53 / $1,679.70 / $2,384.79
| Professional | | $905.53 | $1,679.70 | $2,384.79 |