- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.21 / $804.47 / $1,759.24
| Professional | | $663.21 | $804.47 | $1,759.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.80 / $1,177.48 / $3,608.22
| Professional | | $969.80 | $1,177.48 | $3,608.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.30 / $1,017.71 / $2,245.82
| Professional | | $702.30 | $1,017.71 | $2,245.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.58 / $1,140.67 / $2,245.82
| Professional | | $847.58 | $1,140.67 | $2,245.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.58 / $1,069.63 / $3,285.30
| Professional | | $847.58 | $1,069.63 | $3,285.30 |