- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.48 / $643.19 / $1,395.56
| Professional | | $531.48 | $643.19 | $1,395.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.53 / $1,429.69 / $4,381.09
| Professional | | $1,177.53 | $1,429.69 | $4,381.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.91 / $800.39 / $1,815.10
| Professional | | $570.91 | $800.39 | $1,815.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.50 / $928.67 / $1,815.10
| Professional | | $690.50 | $928.67 | $1,815.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.75 / $902.33 / $2,623.13
| Professional | | $676.75 | $902.33 | $2,623.13 |