- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.07 / $874.26 / $1,044.38
| Professional | | $692.07 | $874.26 | $1,044.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.75 / $1,125.56 / $1,603.12
| Professional | | $869.75 | $1,125.56 | $1,603.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $856.46 / $1,253.26 / $1,795.12
| Professional | | $856.46 | $1,253.26 | $1,795.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.99 / $1,211.36 / $1,858.30
| Professional | | $1,046.99 | $1,211.36 | $1,858.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.36 / $1,044.38 / $1,621.30
| Professional | | $759.36 | $1,044.38 | $1,621.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.60 / $1,146.36 / $1,654.89
| Professional | | $790.60 | $1,146.36 | $1,654.89 |