- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $851.14 / $1,995.26
| Professional | | $630.96 | $851.14 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,122.02 / $1,621.81
| Professional | | $691.83 | $1,122.02 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $1,698.24
| Professional | | $831.76 | $1,047.13 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,023.29 / $1,905.46
| Professional | | $851.14 | $1,023.29 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,023.29 / $2,041.74
| Professional | | $707.95 | $1,023.29 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $977.24 / $1,621.81
| Professional | | $645.65 | $977.24 | $1,621.81 |