- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $977.24 / $1,905.46
| Professional | | $891.25 | $977.24 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,818.38
| Professional | | $1,778.28 | $1,778.28 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $2,344.23
| Professional | | $1,096.48 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,258.93 / $2,511.89
| Professional | | $977.24 | $1,258.93 | $2,511.89 |