- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.82 / $785.82 / $1,352.82
| Professional | | $785.82 | $785.82 | $1,352.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.88 / $1,044.53 / $1,654.03
| Professional | | $911.88 | $1,044.53 | $1,654.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.69 / $1,179.52 / $1,689.87
| Professional | | $957.69 | $1,179.52 | $1,689.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.87 / $1,129.33 / $1,732.46
| Professional | | $876.87 | $1,129.33 | $1,732.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.82 / $785.82 / $1,352.82
| Professional | | $785.82 | $785.82 | $1,352.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.31 / $1,121.71 / $1,563.54
| Professional | | $796.31 | $1,121.71 | $1,563.54 |