- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.62 / $876.62 / $930.53
| Professional | | $876.62 | $876.62 | $930.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.27 / $1,329.98 / $2,906.04
| Professional | | $1,128.27 | $1,329.98 | $2,906.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.06 / $1,092.24 / $1,825.11
| Professional | | $895.06 | $1,092.24 | $1,825.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.61 / $1,119.67 / $1,825.11
| Professional | | $847.61 | $1,119.67 | $1,825.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.17 / $1,146.32 / $3,332.43
| Professional | | $992.17 | $1,146.32 | $3,332.43 |