- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.01 / $1,003.87 / $1,281.70
| Professional | | $773.01 | $1,003.87 | $1,281.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.36 / $619.85 / $1,337.13
| Professional | | $204.36 | $619.85 | $1,337.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.82 / $1,081.48 / $1,760.96
| Professional | | $717.82 | $1,081.48 | $1,760.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.16 / $1,090.53 / $1,600.80
| Professional | | $958.16 | $1,090.53 | $1,600.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.96 / $673.65 / $1,127.27
| Professional | | $102.96 | $673.65 | $1,127.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.14 / $1,269.34 / $1,794.33
| Professional | | $1,017.14 | $1,269.34 | $1,794.33 |