- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.82 / $1,306.06 / $1,735.05
| Professional | | $373.82 | $1,306.06 | $1,735.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.41 / $1,489.06 / $2,688.98
| Professional | | $545.41 | $1,489.06 | $2,688.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.82 / $858.26 / $2,309.76
| Professional | | $422.82 | $858.26 | $2,309.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.80 / $1,802.34 / $4,219.54
| Professional | | $576.80 | $1,802.34 | $4,219.54 |
- 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
- $1,753.59 / $2,596.96 / $3,948.96
| Professional | | $1,753.59 | $2,596.96 | $3,948.96 |