- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.84 / $977.13 / $1,600.00
| Professional | | $702.84 | $977.13 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.50 / $1,409.23 / $3,618.59
| Professional | | $1,195.50 | $1,409.23 | $3,618.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.73 / $1,412.30 / $1,712.19
| Professional | | $895.73 | $1,412.30 | $1,712.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.73 / $1,321.06 / $1,712.19
| Professional | | $895.73 | $1,321.06 | $1,712.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.19 / $1,111.14 / $3,802.96
| Professional | | $895.19 | $1,111.14 | $3,802.96 |