- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.44 / $1,234.49 / $1,281.97
| Professional | | $893.44 | $1,234.49 | $1,281.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.49 / $1,540.93 / $2,448.53
| Professional | | $249.49 | $1,540.93 | $2,448.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.70 / $1,289.29 / $2,182.14
| Professional | | $720.70 | $1,289.29 | $2,182.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.91 / $1,236.72 / $1,673.59
| Professional | | $961.91 | $1,236.72 | $1,673.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.47 / $676.98 / $1,131.69
| Professional | | $103.47 | $676.98 | $1,131.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.83 / $1,402.42 / $1,940.82
| Professional | | $1,090.83 | $1,402.42 | $1,940.82 |