- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.96 / $768.00 / $990.62
| Professional | | $658.96 | $768.00 | $990.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.66 / $1,005.66 / $1,005.66
| Professional | | $1,005.66 | $1,005.66 | $1,005.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.24 / $1,034.66 / $1,216.61
| Professional | | $899.24 | $1,034.66 | $1,216.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.12 / $1,010.32 / $1,178.70
| Professional | | $926.12 | $1,010.32 | $1,178.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.61 / $1,218.47 / $1,368.66
| Professional | | $485.61 | $1,218.47 | $1,368.66 |