- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.84 / $961.91 / $1,163.59
| Professional | | $812.84 | $961.91 | $1,163.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.87 / $1,045.36 / $1,624.53
| Professional | | $885.87 | $1,045.36 | $1,624.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.80 / $1,250.61 / $1,799.60
| Professional | | $899.80 | $1,250.61 | $1,799.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.94 / $1,461.22 / $2,299.76
| Professional | | $1,039.94 | $1,461.22 | $2,299.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,169.74
| Professional | | $32.34 | $32.34 | $1,169.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.61 / $1,382.72 / $2,231.81
| Professional | | $1,033.61 | $1,382.72 | $2,231.81 |