- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.20 / $795.89 / $1,015.76
| Professional | | $679.20 | $795.89 | $1,015.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.62 / $1,080.09 / $1,589.24
| Professional | | $834.62 | $1,080.09 | $1,589.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.90 / $1,241.71 / $1,844.89
| Professional | | $860.90 | $1,241.71 | $1,844.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.92 / $1,200.86 / $1,842.20
| Professional | | $1,037.92 | $1,200.86 | $1,842.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.20 / $795.89 / $1,015.76
| Professional | | $679.20 | $795.89 | $1,015.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.67 / $1,070.88 / $1,685.14
| Professional | | $769.67 | $1,070.88 | $1,685.14 |