- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.03 / $872.56 / $932.40
| Professional | | $643.03 | $872.56 | $932.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.00 / $734.00 / $2,604.01
| Professional | | $734.00 | $734.00 | $2,604.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.74 / $1,255.35 / $1,641.15
| Professional | | $820.74 | $1,255.35 | $1,641.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.21 / $1,111.52 / $1,641.15
| Professional | | $765.21 | $1,111.52 | $1,641.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.10 / $1,030.78 / $2,996.55
| Professional | | $1,002.10 | $1,030.78 | $2,996.55 |