- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.71 / $1,010.96 / $1,137.14
| Professional | | $770.71 | $1,010.96 | $1,137.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.53 / $1,218.45 / $1,775.42
| Professional | | $941.53 | $1,218.45 | $1,775.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.09 / $1,385.94 / $2,055.54
| Professional | | $960.09 | $1,385.94 | $2,055.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.52 / $1,341.56 / $2,058.03
| Professional | | $1,159.52 | $1,341.56 | $2,058.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.71 / $1,013.24 / $1,137.14
| Professional | | $770.71 | $1,013.24 | $1,137.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.21 / $1,190.75 / $1,879.47
| Professional | | $821.21 | $1,190.75 | $1,879.47 |