- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.14 / $1,334.55 / $1,863.38
| Professional | | $354.14 | $1,334.55 | $1,863.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.48 / $1,710.55 / $3,250.99
| Professional | | $431.48 | $1,710.55 | $3,250.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.23 / $821.15 / $2,357.76
| Professional | | $411.23 | $821.15 | $2,357.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $538.07 / $1,685.41 / $4,361.43
| Professional | | $538.07 | $1,685.41 | $4,361.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,808.24 / $2,583.94 / $4,040.55
| Professional | | $1,808.24 | $2,583.94 | $4,040.55 |