- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $1,995.26
| Professional | | $691.83 | $870.96 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,096.48 / $1,621.81
| Professional | | $660.69 | $1,096.48 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $1,698.24
| Professional | | $851.14 | $1,122.02 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,862.09
| Professional | | $812.83 | $1,000.00 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $2,238.72
| Professional | | $758.58 | $1,047.13 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $1,584.89
| Professional | | $676.08 | $954.99 | $1,584.89 |