- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.57 / $1,097.56 / $1,097.56
| Professional | | $896.57 | $1,097.56 | $1,097.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.20 / $939.59 / $1,394.91
| Professional | | $764.20 | $939.59 | $1,394.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.22 / $1,097.56 / $1,535.31
| Professional | | $938.22 | $1,097.56 | $1,535.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.77 / $896.95 / $1,395.65
| Professional | | $805.77 | $896.95 | $1,395.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.57 / $1,097.56 / $1,097.56
| Professional | | $896.57 | $1,097.56 | $1,097.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.32 / $1,129.06 / $1,394.24
| Professional | | $836.32 | $1,129.06 | $1,394.24 |