- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $645.65 / $2,290.87
| Professional | | $416.87 | $645.65 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,380.38 / $1,445.44
| Professional | | $1,174.90 | $1,380.38 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $831.76 / $1,862.09
| Professional | | $575.44 | $831.76 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,047.13 / $1,047.13
| Professional | | $676.08 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $851.14 / $1,698.24
| Professional | | $602.56 | $851.14 | $1,698.24 |