- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $1,905.46
| Professional | | $660.69 | $891.25 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,445.44
| Professional | | $1,230.27 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,023.29 / $1,659.59
| Professional | | $741.31 | $1,023.29 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,023.29 / $1,230.27
| Professional | | $776.25 | $1,023.29 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $3,090.30
| Professional | | $870.96 | $1,047.13 | $3,090.30 |