- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.58 / $774.58 / $1,001.98
| Professional | | $774.58 | $774.58 | $1,001.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.43 / $963.60 / $1,391.88
| Professional | | $816.43 | $963.60 | $1,391.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.02 / $1,040.88 / $1,452.21
| Professional | | $838.02 | $1,040.88 | $1,452.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.92 / $1,048.27 / $1,608.09
| Professional | | $813.92 | $1,048.27 | $1,608.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.26 / $774.58 / $1,001.98
| Professional | | $746.26 | $774.58 | $1,001.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.89 / $974.26 / $1,452.46
| Professional | | $692.89 | $974.26 | $1,452.46 |