- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.32 / $489.76 / $1,898.72
| Professional | | $340.32 | $489.76 | $1,898.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.72 / $679.78 / $1,020.54
| Professional | | $367.72 | $679.78 | $1,020.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.38 / $1,047.27 / $1,529.37
| Professional | | $662.38 | $1,047.27 | $1,529.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.01 / $1,071.07 / $2,800.00
| Professional | | $647.01 | $1,071.07 | $2,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.96 / $1,005.36 / $1,407.05
| Professional | | $728.96 | $1,005.36 | $1,407.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.01 / $1,071.07 / $1,393.56
| Professional | | $647.01 | $1,071.07 | $1,393.56 |