- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.17 / $819.85 / $3,848.20
| Professional | | $678.17 | $819.85 | $3,848.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.93 / $1,129.93 / $2,708.94
| Professional | | $1,129.93 | $1,129.93 | $2,708.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.89 / $1,099.71 / $2,708.94
| Professional | | $576.89 | $1,099.71 | $2,708.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.72 / $1,099.71 / $2,708.94
| Professional | | $751.72 | $1,099.71 | $2,708.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.36 / $1,027.54 / $3,324.92
| Professional | | $807.36 | $1,027.54 | $3,324.92 |