- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $794.33 / $1,949.84
| Professional | | $645.65 | $794.33 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,047.13 / $1,513.56
| Professional | | $660.69 | $1,047.13 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $1,584.89
| Professional | | $794.33 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $1,862.09
| Professional | | $812.83 | $977.24 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $977.24 / $1,995.26
| Professional | | $676.08 | $977.24 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $891.25 / $1,513.56
| Professional | | $602.56 | $891.25 | $1,513.56 |