- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.63 / $1,155.93 / $1,427.98
| Professional | | $830.63 | $1,155.93 | $1,427.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.53 / $970.53 / $1,538.55
| Professional | | $970.53 | $970.53 | $1,538.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.42 / $2,005.28 / $2,659.67
| Professional | | $1,375.42 | $2,005.28 | $2,659.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.68 / $1,902.89 / $2,919.14
| Professional | | $1,644.68 | $1,902.89 | $2,919.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.63 / $1,281.34 / $1,427.98
| Professional | | $830.63 | $1,281.34 | $1,427.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.18 / $1,337.48 / $3,137.11
| Professional | | $887.18 | $1,337.48 | $3,137.11 |