- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.59 / $975.90 / $1,324.16
| Professional | | $638.59 | $975.90 | $1,324.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.61 / $1,377.61 / $1,546.55
| Professional | | $1,377.61 | $1,377.61 | $1,546.55 |
- 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
- $742.34 / $742.34 / $742.34
| Professional | | $742.34 | $742.34 | $742.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.56 / $946.66 / $3,224.48
| Professional | | $771.56 | $946.66 | $3,224.48 |