- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.28 / $604.04 / $2,275.06
| Professional | | $432.28 | $604.04 | $2,275.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.24 / $1,045.86 / $2,231.62
| Professional | | $887.24 | $1,045.86 | $2,231.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.80 / $754.35 / $1,061.97
| Professional | | $487.80 | $754.35 | $1,061.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.80 / $754.35 / $1,038.81
| Professional | | $487.80 | $754.35 | $1,038.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.63 / $826.93 / $2,507.30
| Professional | | $676.63 | $826.93 | $2,507.30 |