- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $933.25 / $2,187.76
| Professional | | $724.44 | $933.25 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,174.90 / $1,949.84
| Professional | | $724.44 | $1,174.90 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $1,819.70
| Professional | | $912.01 | $1,202.26 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $2,041.74
| Professional | | $891.25 | $1,096.48 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,148.15 / $2,570.40
| Professional | | $831.76 | $1,148.15 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $1,819.70
| Professional | | $794.33 | $1,122.02 | $1,819.70 |