- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.72 / $783.84 / $1,045.11
| Professional | | $627.72 | $783.84 | $1,045.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.83 / $1,075.83 / $1,199.80
| Professional | | $1,075.83 | $1,075.83 | $1,199.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.05 / $1,223.23 / $1,223.23
| Professional | | $124.05 | $1,223.23 | $1,223.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.91 / $1,551.35 / $2,063.29
| Professional | | $1,315.91 | $1,551.35 | $2,063.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.07 / $833.89 / $1,219.07
| Professional | | $541.07 | $833.89 | $1,219.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.80 / $1,054.67 / $1,378.28
| Professional | | $961.80 | $1,054.67 | $1,378.28 |