- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.98 / $1,451.56 / $2,389.69
| Professional | | $814.98 | $1,451.56 | $2,389.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.53 / $2,267.37 / $2,690.13
| Professional | | $1,009.53 | $2,267.37 | $2,690.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.52 / $1,284.22 / $2,686.56
| Professional | | $333.52 | $1,284.22 | $2,686.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.39 / $849.66 / $1,252.35
| Professional | | $321.39 | $849.66 | $1,252.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.54 / $1,568.53 / $2,535.58
| Professional | | $321.54 | $1,568.53 | $2,535.58 |