- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.52 / $1,065.36 / $1,685.75
| Professional | | $695.52 | $1,065.36 | $1,685.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.93 / $1,037.70 / $1,409.24
| Professional | | $762.93 | $1,037.70 | $1,409.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.50 / $1,263.31 / $1,531.28
| Professional | | $973.50 | $1,263.31 | $1,531.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $1,095.71 / $1,378.47
| Professional | | $32.34 | $1,095.71 | $1,378.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.65 / $1,352.30 / $1,700.46
| Professional | | $1,031.65 | $1,352.30 | $1,700.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.86 / $1,217.42 / $1,714.48
| Professional | | $872.86 | $1,217.42 | $1,714.48 |