- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.67 / $1,159.88 / $1,159.88
| Professional | | $876.67 | $1,159.88 | $1,159.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.03 / $978.89 / $1,476.58
| Professional | | $803.03 | $978.89 | $1,476.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.99 / $1,159.88 / $1,619.05
| Professional | | $975.99 | $1,159.88 | $1,619.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.47 / $934.46 / $1,454.02
| Professional | | $839.47 | $934.46 | $1,454.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.06 / $876.67 / $1,159.88
| Professional | | $790.06 | $876.67 | $1,159.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.75 / $1,210.06 / $1,454.02
| Professional | | $866.75 | $1,210.06 | $1,454.02 |