- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.82 / $790.24 / $1,083.07
| Professional | | $688.82 | $790.24 | $1,083.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.57 / $1,099.50 / $3,369.23
| Professional | | $905.57 | $1,099.50 | $3,369.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.76 / $1,022.47 / $2,205.90
| Professional | | $720.76 | $1,022.47 | $2,205.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.93 / $1,124.50 / $2,205.90
| Professional | | $816.93 | $1,124.50 | $2,205.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.84 / $1,002.73 / $3,166.50
| Professional | | $795.84 | $1,002.73 | $3,166.50 |