- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.91 / $1,006.74 / $1,123.63
| Professional | | $932.91 | $1,006.74 | $1,123.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.85 / $1,088.33 / $1,243.96
| Professional | | $969.85 | $1,088.33 | $1,243.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.19 / $1,029.33 / $2,117.91
| Professional | | $771.19 | $1,029.33 | $2,117.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.12 / $1,085.04 / $1,792.19
| Professional | | $841.12 | $1,085.04 | $1,792.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.46 / $1,213.83 / $1,769.95
| Professional | | $809.46 | $1,213.83 | $1,769.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.83 / $670.83 / $1,182.17
| Professional | | $670.83 | $670.83 | $1,182.17 |