- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.54 / $641.16 / $3,996.10
| Professional | | $632.54 | $641.16 | $3,996.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.00 / $807.00 / $930.68
| Professional | | $807.00 | $807.00 | $930.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.66 / $1,010.53 / $1,946.53
| Professional | | $706.66 | $1,010.53 | $1,946.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.23 / $1,053.67 / $1,686.56
| Professional | | $792.23 | $1,053.67 | $1,686.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.83 / $917.55 / $1,536.29
| Professional | | $672.83 | $917.55 | $1,536.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.59 / $911.06 / $1,132.36
| Professional | | $748.59 | $911.06 | $1,132.36 |