- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.67 / $934.96 / $3,887.00
| Professional | | $608.67 | $934.96 | $3,887.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.48 / $1,197.98 / $3,609.64
| Professional | | $993.48 | $1,197.98 | $3,609.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.54 / $1,032.58 / $3,609.64
| Professional | | $780.54 | $1,032.58 | $3,609.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $780.54 / $1,032.58 / $3,609.64
| Professional | | $780.54 | $1,032.58 | $3,609.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.09 / $1,161.86 / $4,430.43
| Professional | | $948.09 | $1,161.86 | $4,430.43 |