- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $812.83 / $1,698.24
| Professional | | $588.84 | $812.83 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $1,202.26
| Professional | | $1,023.29 | $1,023.29 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $912.01 / $1,513.56
| Professional | | $575.44 | $912.01 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $933.25 / $1,122.02
| Professional | | $691.83 | $933.25 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $954.99 / $2,754.23
| Professional | | $776.25 | $954.99 | $2,754.23 |