- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $891.25 / $3,090.30
| Professional | | $562.34 | $891.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $3,162.28
| Professional | | $1,047.13 | $1,230.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,096.48 / $2,570.40
| Professional | | $741.31 | $1,096.48 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $1,445.44
| Professional | | $912.01 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,096.48 / $2,041.74
| Professional | | $831.76 | $1,096.48 | $2,041.74 |