- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.65 / $1,016.26 / $1,335.01
| Professional | | $909.65 | $1,016.26 | $1,335.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.04 / $1,336.17 / $2,210.29
| Professional | | $838.04 | $1,336.17 | $2,210.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.13 / $938.78 / $1,160.02
| Professional | | $488.13 | $938.78 | $1,160.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.48 / $736.15 / $1,284.31
| Professional | | $72.48 | $736.15 | $1,284.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.35 / $1,111.70 / $1,965.59
| Professional | | $801.35 | $1,111.70 | $1,965.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.31 / $770.31 / $971.46
| Professional | | $770.31 | $770.31 | $971.46 |