- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.91 / $1,328.69 / $1,878.71
| Professional | | $689.91 | $1,328.69 | $1,878.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.45 / $693.32 / $1,144.80
| Professional | | $582.45 | $693.32 | $1,144.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.26 / $964.26 / $2,087.55
| Professional | | $752.26 | $964.26 | $2,087.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.65 / $1,495.57 / $3,361.79
| Professional | | $853.65 | $1,495.57 | $3,361.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,851.55
| Professional | | $32.34 | $32.34 | $1,851.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.17 / $2,022.03 / $3,216.68
| Professional | | $1,377.17 | $2,022.03 | $3,216.68 |