- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $870.96 / $1,659.59
| Professional | | $741.31 | $870.96 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,148.15 / $1,548.82
| Professional | | $676.08 | $1,148.15 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $1,621.81
| Professional | | $851.14 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $1,479.11
| Professional | | $831.76 | $1,023.29 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $2,290.87
| Professional | | $741.31 | $1,047.13 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $1,621.81
| Professional | | $741.31 | $1,047.13 | $1,621.81 |