- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.10 / $903.11 / $1,086.46
| Professional | | $720.10 | $903.11 | $1,086.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.63 / $1,169.41 / $1,660.56
| Professional | | $903.63 | $1,169.41 | $1,660.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.64 / $1,303.75 / $1,858.75
| Professional | | $885.64 | $1,303.75 | $1,858.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.50 / $1,254.77 / $1,924.88
| Professional | | $1,084.50 | $1,254.77 | $1,924.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.10 / $1,009.20 / $1,086.46
| Professional | | $720.10 | $1,009.20 | $1,086.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.00 / $1,173.34 / $1,723.29
| Professional | | $792.00 | $1,173.34 | $1,723.29 |