- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.33 / $1,032.03 / $1,379.72
| Professional | | $843.33 | $1,032.03 | $1,379.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.69 / $1,264.19 / $2,373.79
| Professional | | $464.69 | $1,264.19 | $2,373.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.35 / $1,501.85 / $1,501.85
| Professional | | $1,252.35 | $1,501.85 | $1,501.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.84 / $1,117.82 / $1,688.06
| Professional | | $905.84 | $1,117.82 | $1,688.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.71 / $1,086.48 / $2,175.12
| Professional | | $528.71 | $1,086.48 | $2,175.12 |