- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.02 / $806.03 / $965.27
| Professional | | $640.02 | $806.03 | $965.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.79 / $1,041.50 / $1,481.94
| Professional | | $804.79 | $1,041.50 | $1,481.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.72 / $1,179.18 / $1,656.85
| Professional | | $791.72 | $1,179.18 | $1,656.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.85 / $1,119.80 / $1,717.84
| Professional | | $967.85 | $1,119.80 | $1,717.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.02 / $923.82 / $965.27
| Professional | | $640.02 | $923.82 | $965.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.61 / $1,008.41 / $1,538.79
| Professional | | $733.61 | $1,008.41 | $1,538.79 |