- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $851.14 / $2,041.74
| Professional | | $676.08 | $851.14 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,096.48 / $1,584.89
| Professional | | $676.08 | $1,096.48 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $1,659.59
| Professional | | $831.76 | $1,047.13 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,000.00 / $1,905.46
| Professional | | $831.76 | $1,000.00 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,023.29 / $2,041.74
| Professional | | $724.44 | $1,023.29 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $977.24 / $1,621.81
| Professional | | $645.65 | $977.24 | $1,621.81 |