- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $677.57 / $1,328.69 / $1,966.93
| Professional | | $677.57 | $1,328.69 | $1,966.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.96 / $978.91 / $1,413.40
| Professional | | $602.96 | $978.91 | $1,413.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.35 / $1,753.62 / $2,192.03
| Professional | | $1,461.35 | $1,753.62 | $2,192.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.25 / $1,394.27 / $2,728.99
| Professional | | $781.25 | $1,394.27 | $2,728.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.75 / $1,787.02 / $3,325.56
| Professional | | $1,376.75 | $1,787.02 | $3,325.56 |