- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $2,344.23
| Professional | | $758.58 | $1,071.52 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,380.38 / $1,995.26
| Professional | | $851.14 | $1,380.38 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,230.27 / $2,089.30
| Professional | | $954.99 | $1,230.27 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $2,398.83
| Professional | | $1,071.52 | $1,258.93 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,174.90 / $2,570.40
| Professional | | $776.25 | $1,174.90 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $1,905.46
| Professional | | $794.33 | $1,122.02 | $1,905.46 |