- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.34 / $1,361.83 / $2,013.60
| Professional | | $694.34 | $1,361.83 | $2,013.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.18 / $1,504.59 / $2,994.25
| Professional | | $703.18 | $1,504.59 | $2,994.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $763.86 / $1,117.24 / $1,705.36
| Professional | | $763.86 | $1,117.24 | $1,705.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.28 / $1,142.81 / $1,977.58
| Professional | | $178.28 | $1,142.81 | $1,977.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.80 / $1,742.03 / $3,133.44
| Professional | | $1,230.80 | $1,742.03 | $3,133.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.46 / $1,239.85 / $1,239.85
| Professional | | $573.46 | $1,239.85 | $1,239.85 |