- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $812.83 / $1,862.09
| Professional | | $645.65 | $812.83 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,047.13 / $1,548.82
| Professional | | $660.69 | $1,047.13 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,023.29 / $1,621.81
| Professional | | $741.31 | $1,023.29 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,000.00 / $1,862.09
| Professional | | $831.76 | $1,000.00 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $977.24 / $1,995.26
| Professional | | $645.65 | $977.24 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $912.01 / $1,513.56
| Professional | | $616.60 | $912.01 | $1,513.56 |