- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.86 / $810.04 / $990.11
| Professional | | $635.86 | $810.04 | $990.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.97 / $1,037.84 / $1,464.91
| Professional | | $801.97 | $1,037.84 | $1,464.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.00 / $1,174.90 / $1,659.32
| Professional | | $784.00 | $1,174.90 | $1,659.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.72 / $1,106.92 / $1,698.08
| Professional | | $956.72 | $1,106.92 | $1,698.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.86 / $876.25 / $990.11
| Professional | | $635.86 | $876.25 | $990.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.82 / $1,000.89 / $1,528.76
| Professional | | $718.82 | $1,000.89 | $1,528.76 |