- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.37 / $962.00 / $1,154.15
| Professional | | $766.37 | $962.00 | $1,154.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.58 / $1,245.69 / $1,767.86
| Professional | | $962.58 | $1,245.69 | $1,767.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.04 / $1,384.98 / $1,979.81
| Professional | | $943.04 | $1,384.98 | $1,979.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.57 / $1,335.84 / $2,049.25
| Professional | | $1,154.57 | $1,335.84 | $2,049.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.37 / $1,065.00 / $1,154.15
| Professional | | $766.37 | $1,065.00 | $1,154.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.15 / $1,241.66 / $1,834.71
| Professional | | $877.15 | $1,241.66 | $1,834.71 |