- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.77 / $817.82 / $981.07
| Professional | | $649.77 | $817.82 | $981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.10 / $1,056.13 / $1,504.66
| Professional | | $816.10 | $1,056.13 | $1,504.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.12 / $1,167.82 / $1,680.62
| Professional | | $804.12 | $1,167.82 | $1,680.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.68 / $1,136.96 / $1,744.16
| Professional | | $982.68 | $1,136.96 | $1,744.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.77 / $819.48 / $981.07
| Professional | | $649.77 | $819.48 | $981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.74 / $1,053.67 / $1,562.72
| Professional | | $744.74 | $1,053.67 | $1,562.72 |