- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.46 / $702.46 / $1,226.74
| Professional | | $702.46 | $702.46 | $1,226.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.01 / $935.00 / $1,477.31
| Professional | | $815.01 | $935.00 | $1,477.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.49 / $1,053.18 / $1,508.86
| Professional | | $852.49 | $1,053.18 | $1,508.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.18 / $1,008.67 / $1,547.36
| Professional | | $783.18 | $1,008.67 | $1,547.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.46 / $702.46 / $1,226.74
| Professional | | $702.46 | $702.46 | $1,226.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.50 / $998.06 / $1,397.69
| Professional | | $752.50 | $998.06 | $1,397.69 |