- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.71 / $877.58 / $1,048.76
| Professional | | $696.71 | $877.58 | $1,048.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.75 / $1,133.33 / $1,612.59
| Professional | | $875.75 | $1,133.33 | $1,612.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.71 / $1,258.51 / $1,803.46
| Professional | | $861.71 | $1,258.51 | $1,803.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.17 / $1,218.52 / $1,869.27
| Professional | | $1,053.17 | $1,218.52 | $1,869.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.71 / $939.11 / $1,048.76
| Professional | | $696.71 | $939.11 | $1,048.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.32 / $1,094.41 / $1,675.29
| Professional | | $697.32 | $1,094.41 | $1,675.29 |