- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.39 / $865.31 / $1,039.54
| Professional | | $689.39 | $865.31 | $1,039.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.16 / $1,119.61 / $1,592.40
| Professional | | $865.16 | $1,119.61 | $1,592.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.78 / $1,247.45 / $1,780.19
| Professional | | $849.78 | $1,247.45 | $1,780.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.98 / $1,203.26 / $1,845.86
| Professional | | $1,039.98 | $1,203.26 | $1,845.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.39 / $932.42 / $1,039.54
| Professional | | $689.39 | $932.42 | $1,039.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.06 / $1,143.83 / $1,651.34
| Professional | | $790.06 | $1,143.83 | $1,651.34 |