- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.08 / $816.60 / $1,455.19
| Professional | | $800.08 | $816.60 | $1,455.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.91 / $1,085.53 / $1,718.99
| Professional | | $947.91 | $1,085.53 | $1,718.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.32 / $1,224.61 / $1,754.48
| Professional | | $1,014.32 | $1,224.61 | $1,754.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.31 / $1,173.68 / $1,800.49
| Professional | | $911.31 | $1,173.68 | $1,800.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.08 / $816.60 / $1,455.19
| Professional | | $800.08 | $816.60 | $1,455.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.11 / $1,212.75 / $1,625.86
| Professional | | $906.11 | $1,212.75 | $1,625.86 |