- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.21 / $946.02 / $1,062.22
| Professional | | $720.21 | $946.02 | $1,062.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.53 / $1,131.74 / $1,659.29
| Professional | | $874.53 | $1,131.74 | $1,659.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.77 / $1,295.53 / $1,922.69
| Professional | | $897.77 | $1,295.53 | $1,922.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.67 / $1,253.81 / $1,923.41
| Professional | | $1,083.67 | $1,253.81 | $1,923.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.21 / $950.82 / $1,062.22
| Professional | | $720.21 | $950.82 | $1,062.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.78 / $1,122.50 / $1,739.72
| Professional | | $805.78 | $1,122.50 | $1,739.72 |