- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.28 / $819.91 / $1,177.83
| Professional | | $690.28 | $819.91 | $1,177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.72 / $1,103.84 / $1,363.18
| Professional | | $1,040.72 | $1,103.84 | $1,363.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.22 / $1,110.05 / $1,778.07
| Professional | | $781.22 | $1,110.05 | $1,778.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.22 / $1,109.96 / $1,778.07
| Professional | | $781.22 | $1,109.96 | $1,778.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.53 / $1,116.78 / $2,271.96
| Professional | | $866.53 | $1,116.78 | $2,271.96 |