- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.02 / $642.58 / $1,274.75
| Professional | | $501.02 | $642.58 | $1,274.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.61 / $1,140.20 / $2,371.88
| Professional | | $115.61 | $1,140.20 | $2,371.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.14 / $1,027.14 / $1,027.14
| Professional | | $1,027.14 | $1,027.14 | $1,027.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.68 / $1,013.68 / $1,013.68
| Professional | | $1,013.68 | $1,013.68 | $1,013.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.97 / $803.10 / $943.28
| Professional | | $619.97 | $803.10 | $943.28 |