- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.26 / $1,153.25 / $1,309.68
| Professional | | $912.26 | $1,153.25 | $1,309.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.40 / $1,427.28 / $2,478.96
| Professional | | $255.40 | $1,427.28 | $2,478.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.25 / $1,255.40 / $2,248.81
| Professional | | $738.25 | $1,255.40 | $2,248.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.81 / $1,131.42 / $1,650.19
| Professional | | $978.81 | $1,131.42 | $1,650.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.56 / $688.65 / $1,161.11
| Professional | | $68.56 | $688.65 | $1,161.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.56 / $1,325.50 / $1,888.01
| Professional | | $1,063.56 | $1,325.50 | $1,888.01 |