- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.83 / $948.18 / $1,136.71
| Professional | | $754.83 | $948.18 | $1,136.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.46 / $1,227.42 / $1,741.34
| Professional | | $948.46 | $1,227.42 | $1,741.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.05 / $1,364.05 / $1,951.04
| Professional | | $929.05 | $1,364.05 | $1,951.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.26 / $1,315.81 / $2,018.52
| Professional | | $1,137.26 | $1,315.81 | $2,018.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.83 / $1,039.30 / $1,136.71
| Professional | | $754.83 | $1,039.30 | $1,136.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.89 / $1,231.80 / $1,807.93
| Professional | | $863.89 | $1,231.80 | $1,807.93 |