- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.85 / $822.48 / $1,004.29
| Professional | | $709.85 | $822.48 | $1,004.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.02 / $1,136.35 / $2,029.23
| Professional | | $812.02 | $1,136.35 | $2,029.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.32 / $1,209.05 / $1,209.05
| Professional | | $1,116.32 | $1,209.05 | $1,209.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.79 / $985.00 / $1,453.13
| Professional | | $790.79 | $985.00 | $1,453.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.83 / $981.41 / $1,246.82
| Professional | | $795.83 | $981.41 | $1,246.82 |