- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.25 / $1,000.78 / $1,114.28
| Professional | | $791.25 | $1,000.78 | $1,114.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.62 / $1,036.88 / $1,596.80
| Professional | | $942.62 | $1,036.88 | $1,596.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.15 / $1,166.95 / $1,671.86
| Professional | | $949.15 | $1,166.95 | $1,671.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.35 / $1,118.36 / $1,715.64
| Professional | | $868.35 | $1,118.36 | $1,715.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.25 / $1,000.78 / $1,114.28
| Professional | | $791.25 | $1,000.78 | $1,114.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.67 / $1,104.52 / $1,547.65
| Professional | | $834.67 | $1,104.52 | $1,547.65 |