- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.96 / $1,110.20 / $1,272.82
| Professional | | $966.96 | $1,110.20 | $1,272.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.87 / $976.71 / $1,525.67
| Professional | | $260.87 | $976.71 | $1,525.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.18 / $1,478.61 / $2,130.36
| Professional | | $1,065.18 | $1,478.61 | $2,130.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.33 / $1,640.25 / $2,329.69
| Professional | | $1,109.33 | $1,640.25 | $2,329.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,384.73
| Professional | | $32.34 | $32.34 | $1,384.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,119.42 / $1,500.95 / $2,439.60
| Professional | | $1,119.42 | $1,500.95 | $2,439.60 |