- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.82 / $677.70 / $1,062.18
| Professional | | $579.82 | $677.70 | $1,062.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.06 / $1,472.53 / $1,911.82
| Professional | | $1,250.06 | $1,472.53 | $1,911.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.19 / $1,428.42 / $1,872.40
| Professional | | $1,150.19 | $1,428.42 | $1,872.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.70 / $1,987.20 / $2,854.40
| Professional | | $893.70 | $1,987.20 | $2,854.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.79 / $1,597.48 / $2,971.50
| Professional | | $667.79 | $1,597.48 | $2,971.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.94 / $1,529.46 / $3,058.92
| Professional | | $1,409.94 | $1,529.46 | $3,058.92 |