- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.03 / $854.62 / $955.16
| Professional | | $651.03 | $854.62 | $955.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.23 / $1,055.01 / $1,631.11
| Professional | | $815.23 | $1,055.01 | $1,631.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.22 / $1,252.31 / $1,758.45
| Professional | | $890.22 | $1,252.31 | $1,758.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.97 / $1,187.05 / $1,820.99
| Professional | | $1,025.97 | $1,187.05 | $1,820.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.03 / $955.16 / $1,160.25
| Professional | | $651.03 | $955.16 | $1,160.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $770.40 / $1,089.24 / $1,628.92
| Professional | | $770.40 | $1,089.24 | $1,628.92 |