- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.63 / $1,067.64 / $4,790.31
| Professional | | $776.63 | $1,067.64 | $4,790.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.21 / $1,408.21 / $3,202.86
| Professional | | $1,408.21 | $1,408.21 | $3,202.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.40 / $1,158.78 / $3,202.86
| Professional | | $912.40 | $1,158.78 | $3,202.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.40 / $1,161.54 / $3,202.86
| Professional | | $912.40 | $1,161.54 | $3,202.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.36 / $1,341.89 / $3,931.16
| Professional | | $993.36 | $1,341.89 | $3,931.16 |