- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.37 / $1,003.72 / $1,120.31
| Professional | | $846.37 | $1,003.72 | $1,120.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.61 / $1,085.60 / $1,378.72
| Professional | | $880.61 | $1,085.60 | $1,378.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $769.72 / $1,041.42 / $2,078.69
| Professional | | $769.72 | $1,041.42 | $2,078.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.35 / $1,082.76 / $1,790.02
| Professional | | $839.35 | $1,082.76 | $1,790.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.83 / $1,032.45 / $1,711.14
| Professional | | $762.83 | $1,032.45 | $1,711.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.33 / $780.33 / $1,179.78
| Professional | | $780.33 | $780.33 | $1,179.78 |