- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.17 / $910.83 / $1,009.02
| Professional | | $691.17 | $910.83 | $1,009.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.23 / $1,075.71 / $1,593.66
| Professional | | $831.23 | $1,075.71 | $1,593.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.23 / $1,245.09 / $1,849.40
| Professional | | $863.23 | $1,245.09 | $1,849.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.81 / $1,204.22 / $1,847.33
| Professional | | $1,040.81 | $1,204.22 | $1,847.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.94 / $800.00 / $1,009.02
| Professional | | $666.94 | $800.00 | $1,009.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.58 / $1,068.53 / $1,689.67
| Professional | | $764.58 | $1,068.53 | $1,689.67 |