- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $2,041.74
| Professional | | $691.83 | $1,000.00 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,096.48 / $1,621.81
| Professional | | $676.08 | $1,096.48 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,258.93 / $2,089.30
| Professional | | $851.14 | $1,258.93 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,380.38 / $2,454.71
| Professional | | $831.76 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $2,570.40
| Professional | | $758.58 | $1,148.15 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,122.02 / $2,137.96
| Professional | | $724.44 | $1,122.02 | $2,137.96 |