- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.63 / $694.43 / $1,463.95
| Professional | | $537.63 | $694.43 | $1,463.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.30 / $1,232.30 / $2,564.06
| Professional | | $1,232.30 | $1,232.30 | $2,564.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.96 / $2,032.96 / $2,032.96
| Professional | | $2,032.96 | $2,032.96 | $2,032.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.98 / $1,078.08 / $1,078.08
| Professional | | $66.98 | $1,078.08 | $1,078.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.72 / $842.23 / $1,019.48
| Professional | | $622.72 | $842.23 | $1,019.48 |