- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.18 / $963.13 / $1,155.05
| Professional | | $767.18 | $963.13 | $1,155.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.64 / $1,247.07 / $1,769.12
| Professional | | $963.64 | $1,247.07 | $1,769.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.71 / $1,386.06 / $1,982.06
| Professional | | $943.71 | $1,386.06 | $1,982.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.40 / $1,336.80 / $2,050.71
| Professional | | $1,155.40 | $1,336.80 | $2,050.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.18 / $1,091.45 / $1,155.05
| Professional | | $767.18 | $1,091.45 | $1,155.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.84 / $1,251.05 / $1,836.08
| Professional | | $877.84 | $1,251.05 | $1,836.08 |