- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.92 / $1,015.70 / $1,708.16
| Professional | | $529.92 | $1,015.70 | $1,708.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.74 / $1,028.74 / $1,028.74
| Professional | | $1,028.74 | $1,028.74 | $1,028.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $742.34
| Professional | | $742.34 | $742.34 | $742.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.55 / $1,546.55 / $1,546.55
| Professional | | $1,546.55 | $1,546.55 | $1,546.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.65 / $771.56 / $1,355.13
| Professional | | $696.65 | $771.56 | $1,355.13 |