- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.65 / $1,168.81 / $1,168.81
| Professional | | $864.65 | $1,168.81 | $1,168.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.38 / $1,009.54 / $1,475.19
| Professional | | $815.38 | $1,009.54 | $1,475.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.31 / $1,168.81 / $1,658.82
| Professional | | $960.31 | $1,168.81 | $1,658.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.76 / $963.72 / $1,499.55
| Professional | | $865.76 | $963.72 | $1,499.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.65 / $1,168.81 / $1,168.81
| Professional | | $864.65 | $1,168.81 | $1,168.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.57 / $1,115.02 / $1,321.36
| Professional | | $824.57 | $1,115.02 | $1,321.36 |