- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.65 / $1,013.27 / $2,026.79
| Professional | | $811.65 | $1,013.27 | $2,026.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.53 / $1,141.11 / $1,762.93
| Professional | | $547.53 | $1,141.11 | $1,762.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.18 / $1,337.93 / $1,825.89
| Professional | | $863.18 | $1,337.93 | $1,825.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $166.30 / $1,404.73
| Professional | | $32.34 | $166.30 | $1,404.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.70 / $1,408.83 / $2,095.94
| Professional | | $919.70 | $1,408.83 | $2,095.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.13 / $1,526.20 / $2,377.35
| Professional | | $1,104.13 | $1,526.20 | $2,377.35 |