- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $812.83 / $1,445.44
| Professional | | $660.69 | $812.83 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,000.00 / $1,318.26
| Professional | | $588.84 | $1,000.00 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $891.25 / $1,445.44
| Professional | | $794.33 | $891.25 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $891.25 / $1,288.25
| Professional | | $724.44 | $891.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $891.25 / $1,905.46
| Professional | | $676.08 | $891.25 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $954.99 / $1,412.54
| Professional | | $707.95 | $954.99 | $1,412.54 |