- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $812.83 / $1,513.56
| Professional | | $724.44 | $812.83 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $2,691.53
| Professional | | $1,122.02 | $1,122.02 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,047.13 / $3,162.28
| Professional | | $562.34 | $1,047.13 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $1,862.09
| Professional | | $758.58 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,023.29 / $1,949.84
| Professional | | $741.31 | $1,023.29 | $1,949.84 |