- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.90 / $1,064.78 / $1,664.56
| Professional | | $765.90 | $1,064.78 | $1,664.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.76 / $1,450.78 / $3,779.03
| Professional | | $1,230.76 | $1,450.78 | $3,779.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.75 / $1,543.62 / $1,799.65
| Professional | | $940.75 | $1,543.62 | $1,799.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.75 / $1,426.56 / $1,799.65
| Professional | | $940.75 | $1,426.56 | $1,799.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.80 / $1,175.21 / $4,059.97
| Professional | | $1,016.80 | $1,175.21 | $4,059.97 |