- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.07 / $798.07 / $1,388.56
| Professional | | $798.07 | $798.07 | $1,388.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.09 / $1,062.74 / $1,677.08
| Professional | | $925.09 | $1,062.74 | $1,677.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.76 / $1,194.93 / $1,711.95
| Professional | | $958.76 | $1,194.93 | $1,711.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.09 / $1,145.07 / $1,756.60
| Professional | | $889.09 | $1,145.07 | $1,756.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.07 / $798.07 / $1,388.56
| Professional | | $798.07 | $798.07 | $1,388.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.62 / $1,173.75 / $1,752.13
| Professional | | $885.62 | $1,173.75 | $1,752.13 |