- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.38 / $859.64 / $1,079.35
| Professional | | $684.38 | $859.64 | $1,079.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.55 / $1,250.83 / $1,927.33
| Professional | | $966.55 | $1,250.83 | $1,927.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.98 / $1,395.73 / $2,002.91
| Professional | | $1,013.98 | $1,395.73 | $2,002.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.28 / $1,402.61 / $2,151.67
| Professional | | $1,212.28 | $1,402.61 | $2,151.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.38 / $999.13 / $1,079.35
| Professional | | $684.38 | $999.13 | $1,079.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.92 / $1,125.17 / $1,886.31
| Professional | | $790.92 | $1,125.17 | $1,886.31 |