- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $707.95 / $1,905.46
| Professional | | $616.60 | $707.95 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $1,479.11
| Professional | | $630.96 | $1,000.00 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,513.56
| Professional | | $758.58 | $977.24 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $933.25 / $1,778.28
| Professional | | $776.25 | $933.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $851.14 / $1,905.46
| Professional | | $616.60 | $851.14 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $870.96 / $1,445.44
| Professional | | $588.84 | $870.96 | $1,445.44 |