- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.34 / $922.13 / $1,056.21
| Professional | | $657.34 | $922.13 | $1,056.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.28 / $1,052.48 / $1,522.34
| Professional | | $813.28 | $1,052.48 | $1,522.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.38 / $1,232.22 / $1,701.63
| Professional | | $805.38 | $1,232.22 | $1,701.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.23 / $1,150.32 / $1,764.66
| Professional | | $994.23 | $1,150.32 | $1,764.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.34 / $1,056.21 / $1,086.60
| Professional | | $657.34 | $1,056.21 | $1,086.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.72 / $1,219.09 / $1,764.66
| Professional | | $802.72 | $1,219.09 | $1,764.66 |