- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $1,949.84
| Professional | | $691.83 | $870.96 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,122.02 / $1,659.59
| Professional | | $724.44 | $1,122.02 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,737.80
| Professional | | $741.31 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,071.52 / $1,995.26
| Professional | | $891.25 | $1,071.52 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $2,187.76
| Professional | | $724.44 | $1,047.13 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $977.24 / $1,621.81
| Professional | | $645.65 | $977.24 | $1,621.81 |