- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.51 / $906.85 / $906.85
| Professional | | $709.51 | $906.85 | $906.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.11 / $814.47 / $1,310.97
| Professional | | $688.11 | $814.47 | $1,310.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.16 / $1,110.38 / $1,586.26
| Professional | | $882.16 | $1,110.38 | $1,586.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.55 / $1,383.60 / $4,357.67
| Professional | | $904.55 | $1,383.60 | $4,357.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $872.44
| Professional | | $32.34 | $32.34 | $872.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.70 / $946.59 / $1,401.48
| Professional | | $781.70 | $946.59 | $1,401.48 |