- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.45 / $1,006.78 / $1,135.83
| Professional | | $764.45 | $1,006.78 | $1,135.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.04 / $1,220.40 / $1,757.76
| Professional | | $943.04 | $1,220.40 | $1,757.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.30 / $1,362.99 / $2,045.75
| Professional | | $951.30 | $1,362.99 | $2,045.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.98 / $1,328.21 / $2,037.55
| Professional | | $1,147.98 | $1,328.21 | $2,037.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.45 / $965.05 / $1,135.83
| Professional | | $764.45 | $965.05 | $1,135.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.36 / $1,023.43 / $2,037.55
| Professional | | $772.36 | $1,023.43 | $2,037.55 |