- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.56 / $1,079.51 / $4,899.03
| Professional | | $903.56 | $1,079.51 | $4,899.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.06 / $1,539.55 / $3,306.91
| Professional | | $1,306.06 | $1,539.55 | $3,306.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.64 / $1,427.75 / $1,750.55
| Professional | | $849.64 | $1,427.75 | $1,750.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.64 / $1,361.65 / $1,750.55
| Professional | | $849.64 | $1,361.65 | $1,750.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.13 / $1,232.66 / $3,815.49
| Professional | | $962.13 | $1,232.66 | $3,815.49 |