- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $602.56 / $977.24
| Professional | | $436.52 | $602.56 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,047.13 / $2,238.72
| Professional | | $891.25 | $1,047.13 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $724.44 / $1,047.13
| Professional | | $489.78 | $724.44 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,023.29 / $2,238.72
| Professional | | $1,023.29 | $1,023.29 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $676.08 / $1,778.28
| Professional | | $537.03 | $676.08 | $1,778.28 |