- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.81 / $1,330.02 / $1,330.02
| Professional | | $994.81 | $1,330.02 | $1,330.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.17 / $1,143.40 / $1,675.38
| Professional | | $925.17 | $1,143.40 | $1,675.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.94 / $1,330.02 / $1,878.68
| Professional | | $1,092.94 | $1,330.02 | $1,878.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.55 / $1,091.51 / $1,698.39
| Professional | | $980.55 | $1,091.51 | $1,698.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.81 / $1,330.02 / $1,330.02
| Professional | | $994.81 | $1,330.02 | $1,330.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.76 / $1,262.88 / $1,615.18
| Professional | | $915.76 | $1,262.88 | $1,615.18 |