- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $977.24 / $2,511.89
| Professional | | $724.44 | $977.24 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $3,235.94
| Professional | | $1,348.96 | $1,584.89 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,258.93 / $1,548.82
| Professional | | $741.31 | $1,258.93 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $3,235.94
| Professional | | $1,479.11 | $1,479.11 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $3,311.31
| Professional | | $851.14 | $1,096.48 | $3,311.31 |