- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $954.99 / $2,089.30
| Professional | | $724.44 | $954.99 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,318.26
| Professional | | $1,122.02 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,096.48 / $1,819.70
| Professional | | $588.84 | $1,096.48 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,122.02 / $1,348.96
| Professional | | $831.76 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,148.15 / $3,311.31
| Professional | | $954.99 | $1,148.15 | $3,311.31 |