- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $831.76 / $2,041.74
| Professional | | $602.56 | $831.76 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,071.52 / $1,584.89
| Professional | | $676.08 | $1,071.52 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,698.24
| Professional | | $812.83 | $1,096.48 | $1,698.24 |
- 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
- $707.95 / $1,023.29 / $2,137.96
| Professional | | $707.95 | $1,023.29 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $933.25 / $1,548.82
| Professional | | $691.83 | $933.25 | $1,548.82 |