- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.45 / $1,205.68 / $1,205.68
| Professional | | $802.45 | $1,205.68 | $1,205.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.91 / $1,543.10 / $1,946.90
| Professional | | $145.91 | $1,543.10 | $1,946.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.96 / $1,654.27 / $2,262.05
| Professional | | $914.96 | $1,654.27 | $2,262.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.25 / $945.48 / $1,476.09
| Professional | | $773.25 | $945.48 | $1,476.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.80 / $886.20 / $1,190.35
| Professional | | $92.80 | $886.20 | $1,190.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.88 / $1,108.11 / $1,454.87
| Professional | | $776.88 | $1,108.11 | $1,454.87 |