- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.82 / $729.82 / $1,716.83
| Professional | | $729.82 | $729.82 | $1,716.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.20 / $1,129.40 / $1,753.69
| Professional | | $900.20 | $1,129.40 | $1,753.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.44 / $1,246.36 / $1,978.58
| Professional | | $711.44 | $1,246.36 | $1,978.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.15 / $1,374.40 / $2,036.08
| Professional | | $1,147.15 | $1,374.40 | $2,036.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.82 / $729.82 / $1,716.83
| Professional | | $729.82 | $729.82 | $1,716.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.54 / $1,246.34 / $1,830.43
| Professional | | $884.54 | $1,246.34 | $1,830.43 |