- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.66 / $1,050.95 / $1,308.15
| Professional | | $810.66 | $1,050.95 | $1,308.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.36 / $1,042.35 / $1,509.53
| Professional | | $902.36 | $1,042.35 | $1,509.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.18 / $1,408.45 / $2,037.93
| Professional | | $1,005.18 | $1,408.45 | $2,037.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.05 / $1,224.65 / $2,173.63
| Professional | | $995.05 | $1,224.65 | $2,173.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.66 / $1,050.95 / $1,308.15
| Professional | | $810.66 | $1,050.95 | $1,308.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.34 / $1,396.88 / $1,981.19
| Professional | | $913.34 | $1,396.88 | $1,981.19 |