- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.02 / $900.88 / $1,424.50
| Professional | | $463.02 | $900.88 | $1,424.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.28 / $1,839.23 / $3,210.93
| Professional | | $1,560.28 | $1,839.23 | $3,210.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.27 / $1,382.11 / $1,985.68
| Professional | | $823.27 | $1,382.11 | $1,985.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.27 / $1,345.37 / $1,985.68
| Professional | | $823.27 | $1,345.37 | $1,985.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.57 / $1,213.74 / $3,696.00
| Professional | | $1,074.57 | $1,213.74 | $3,696.00 |