- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.80 / $1,011.89 / $1,011.89
| Professional | | $757.80 | $1,011.89 | $1,011.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.76 / $1,104.46 / $1,595.36
| Professional | | $983.76 | $1,104.46 | $1,595.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.72 / $1,187.13 / $1,818.89
| Professional | | $965.72 | $1,187.13 | $1,818.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.82 / $1,197.53 / $1,837.07
| Professional | | $929.82 | $1,197.53 | $1,837.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.80 / $1,011.89 / $1,011.89
| Professional | | $757.80 | $1,011.89 | $1,011.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.53 / $1,197.53 / $1,674.53
| Professional | | $840.53 | $1,197.53 | $1,674.53 |