- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.10 / $828.10 / $1,256.05
| Professional | | $828.10 | $828.10 | $1,256.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.05 / $1,078.05 / $1,557.21
| Professional | | $907.05 | $1,078.05 | $1,557.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.00 / $1,116.68 / $1,759.82
| Professional | | $1,020.00 | $1,116.68 | $1,759.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.12 / $1,167.01 / $1,790.25
| Professional | | $906.12 | $1,167.01 | $1,790.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.10 / $828.10 / $921.57
| Professional | | $828.10 | $828.10 | $921.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.81 / $1,209.05 / $1,614.21
| Professional | | $886.81 | $1,209.05 | $1,614.21 |