- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.86 / $918.86 / $1,188.36
| Professional | | $918.86 | $918.86 | $1,188.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.83 / $1,141.88 / $1,649.41
| Professional | | $968.83 | $1,141.88 | $1,649.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.11 / $1,233.92 / $1,722.70
| Professional | | $994.11 | $1,233.92 | $1,722.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.63 / $1,242.35 / $1,905.85
| Professional | | $964.63 | $1,242.35 | $1,905.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.86 / $918.86 / $1,188.36
| Professional | | $918.86 | $918.86 | $1,188.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.85 / $1,276.05 / $1,905.85
| Professional | | $821.85 | $1,276.05 | $1,905.85 |