- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.69 / $1,021.68 / $1,154.25
| Professional | | $771.69 | $1,021.68 | $1,154.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.71 / $1,235.50 / $1,772.90
| Professional | | $954.71 | $1,235.50 | $1,772.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.05 / $1,385.67 / $2,073.23
| Professional | | $961.05 | $1,385.67 | $2,073.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.86 / $1,339.66 / $2,055.10
| Professional | | $1,157.86 | $1,339.66 | $2,055.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.69 / $1,036.55 / $1,154.25
| Professional | | $771.69 | $1,036.55 | $1,154.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.68 / $1,187.78 / $1,885.84
| Professional | | $844.68 | $1,187.78 | $1,885.84 |