- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.83 / $1,201.03 / $2,185.98
| Professional | | $781.83 | $1,201.03 | $2,185.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.01 / $989.42 / $1,417.56
| Professional | | $841.01 | $989.42 | $1,417.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.17 / $1,681.52 / $3,264.83
| Professional | | $970.17 | $1,681.52 | $3,264.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.80 / $2,001.64 / $3,213.43
| Professional | | $925.80 | $2,001.64 | $3,213.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.09 / $1,201.03 / $2,185.98
| Professional | | $841.09 | $1,201.03 | $2,185.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.54 / $2,348.50 / $3,327.97
| Professional | | $1,440.54 | $2,348.50 | $3,327.97 |