- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.46 / $934.04 / $1,048.14
| Professional | | $640.46 | $934.04 | $1,048.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.24 / $1,121.02 / $1,623.32
| Professional | | $866.24 | $1,121.02 | $1,623.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.88 / $1,257.77 / $1,895.41
| Professional | | $879.88 | $1,257.77 | $1,895.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.18 / $1,226.63 / $1,881.71
| Professional | | $1,060.18 | $1,226.63 | $1,881.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.46 / $808.61 / $1,048.14
| Professional | | $640.46 | $808.61 | $1,048.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.40 / $1,047.59 / $1,725.84
| Professional | | $713.40 | $1,047.59 | $1,725.84 |