- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $977.24 / $2,290.87
| Professional | | $676.08 | $977.24 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,288.25 / $1,778.28
| Professional | | $831.76 | $1,288.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $2,137.96
| Professional | | $977.24 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $1,905.46
| Professional | | $1,071.52 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,288.25 / $3,090.30
| Professional | | $724.44 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $1,905.46
| Professional | | $933.25 | $1,258.93 | $1,905.46 |