- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.14 / $1,026.40 / $1,663.59
| Professional | | $593.14 | $1,026.40 | $1,663.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.85 / $1,064.00 / $1,359.06
| Professional | | $723.85 | $1,064.00 | $1,359.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.33 / $1,233.42 / $1,518.68
| Professional | | $1,002.33 | $1,233.42 | $1,518.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $1,066.82 / $1,342.13
| Professional | | $32.34 | $1,066.82 | $1,342.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.66 / $1,320.57 / $1,636.83
| Professional | | $1,069.66 | $1,320.57 | $1,636.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.47 / $1,154.40 / $1,642.80
| Professional | | $807.47 | $1,154.40 | $1,642.80 |