- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.30 / $840.52 / $1,019.19
| Professional | | $652.30 | $840.52 | $1,019.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.56 / $1,059.32 / $1,490.78
| Professional | | $818.56 | $1,059.32 | $1,490.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.24 / $1,209.04 / $1,715.06
| Professional | | $795.24 | $1,209.04 | $1,715.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.62 / $1,126.48 / $1,728.08
| Professional | | $973.62 | $1,126.48 | $1,728.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.30 / $952.17 / $1,019.19
| Professional | | $652.30 | $952.17 | $1,019.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.04 / $1,082.05 / $1,449.17
| Professional | | $680.04 | $1,082.05 | $1,449.17 |