- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.72 / $860.75 / $1,002.22
| Professional | | $655.72 | $860.75 | $1,002.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.00 / $866.00 / $1,443.63
| Professional | | $633.00 | $866.00 | $1,443.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.44 / $1,095.31 / $1,879.79
| Professional | | $638.44 | $1,095.31 | $1,879.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.55 / $2,003.00 / $6,882.96
| Professional | | $945.55 | $2,003.00 | $6,882.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.03 / $1,354.84 / $2,152.73
| Professional | | $926.03 | $1,354.84 | $2,152.73 |