- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.88 / $1,000.75 / $2,162.81
| Professional | | $910.88 | $1,000.75 | $2,162.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.37 / $946.00 / $1,081.28
| Professional | | $881.37 | $946.00 | $1,081.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.05 / $980.86 / $2,058.80
| Professional | | $762.05 | $980.86 | $2,058.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.65 / $1,081.85 / $1,787.62
| Professional | | $838.65 | $1,081.85 | $1,787.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.52 / $910.98 / $1,541.84
| Professional | | $699.52 | $910.98 | $1,541.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.80 / $650.80 / $1,176.71
| Professional | | $650.80 | $650.80 | $1,176.71 |