- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.25 / $584.78 / $3,121.96
| Professional | | $481.25 | $584.78 | $3,121.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.58 / $1,276.58 / $2,081.52
| Professional | | $1,276.58 | $1,276.58 | $2,081.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.12 / $872.57 / $2,081.52
| Professional | | $457.12 | $872.57 | $2,081.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.73 / $847.05 / $2,081.52
| Professional | | $612.73 | $847.05 | $2,081.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.77 / $835.49 / $2,554.83
| Professional | | $679.77 | $835.49 | $2,554.83 |