- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,071.52 / $3,235.94
| Professional | | $724.44 | $1,071.52 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $3,801.89
| Professional | | $1,230.27 | $1,445.44 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,412.54 / $1,819.70
| Professional | | $933.25 | $1,412.54 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $3,801.89
| Professional | | $1,737.80 | $1,737.80 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,318.26 / $4,073.80
| Professional | | $1,023.29 | $1,318.26 | $4,073.80 |