- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.60 / $941.68 / $1,050.96
| Professional | | $873.60 | $941.68 | $1,050.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.35 / $972.88 / $1,235.56
| Professional | | $908.35 | $972.88 | $1,235.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.44 / $950.87 / $1,950.27
| Professional | | $722.44 | $950.87 | $1,950.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.05 / $1,016.58 / $1,678.54
| Professional | | $788.05 | $1,016.58 | $1,678.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.87 / $879.59 / $1,489.32
| Professional | | $680.87 | $879.59 | $1,489.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.74 / $641.74 / $1,107.45
| Professional | | $641.74 | $641.74 | $1,107.45 |