- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.14 / $918.71 / $1,031.72
| Professional | | $690.14 | $918.71 | $1,031.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.24 / $1,121.02 / $1,587.34
| Professional | | $866.24 | $1,121.02 | $1,587.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.36 / $1,242.88 / $1,859.04
| Professional | | $862.36 | $1,242.88 | $1,859.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.68 / $1,199.44 / $1,840.00
| Professional | | $1,036.68 | $1,199.44 | $1,840.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.14 / $941.43 / $1,031.72
| Professional | | $690.14 | $941.43 | $1,031.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.26 / $1,111.08 / $1,693.47
| Professional | | $766.26 | $1,111.08 | $1,693.47 |