- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.67 / $749.63 / $3,847.90
| Professional | | $746.67 | $749.63 | $3,847.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.28 / $804.28 / $920.00
| Professional | | $804.28 | $804.28 | $920.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.54 / $1,012.23 / $2,263.65
| Professional | | $680.54 | $1,012.23 | $2,263.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $723.88 / $962.76 / $1,576.85
| Professional | | $723.88 | $962.76 | $1,576.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $614.58 / $907.42 / $1,600.36
| Professional | | $614.58 | $907.42 | $1,600.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.38 / $832.46 / $1,034.72
| Professional | | $556.38 | $832.46 | $1,034.72 |