- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.42 / $881.09 / $3,012.99
| Professional | | $794.42 | $881.09 | $3,012.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.01 / $1,488.07 / $1,669.41
| Professional | | $1,179.01 | $1,488.07 | $1,669.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.53 / $1,282.83 / $2,054.33
| Professional | | $902.53 | $1,282.83 | $2,054.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.53 / $1,282.33 / $2,054.33
| Professional | | $902.53 | $1,282.33 | $2,054.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.34 / $1,289.65 / $2,021.78
| Professional | | $958.34 | $1,289.65 | $2,021.78 |