- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.73 / $818.21 / $1,103.08
| Professional | | $662.73 | $818.21 | $1,103.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.19 / $967.63 / $1,309.07
| Professional | | $751.19 | $967.63 | $1,309.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.83 / $1,181.28 / $2,043.69
| Professional | | $840.83 | $1,181.28 | $2,043.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.69 / $1,027.60 / $1,598.96
| Professional | | $766.69 | $1,027.60 | $1,598.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.73 / $818.21 / $1,103.08
| Professional | | $662.73 | $818.21 | $1,103.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.40 / $1,122.95 / $1,880.00
| Professional | | $840.40 | $1,122.95 | $1,880.00 |