- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $602.56 / $1,148.15
| Professional | | $537.03 | $602.56 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $2,089.30
| Professional | | $1,288.25 | $1,288.25 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $812.83 / $2,398.83
| Professional | | $446.68 | $812.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $812.83 / $1,513.56
| Professional | | $616.60 | $812.83 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $812.83 / $1,584.89
| Professional | | $616.60 | $812.83 | $1,584.89 |