- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $645.65 / $1,621.81
| Professional | | $501.19 | $645.65 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $870.96 / $1,230.27
| Professional | | $616.60 | $870.96 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $954.99 / $1,548.82
| Professional | | $691.83 | $954.99 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $954.99 / $1,548.82
| Professional | | $758.58 | $954.99 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $977.24 / $2,454.71
| Professional | | $501.19 | $977.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $954.99 / $1,412.54
| Professional | | $676.08 | $954.99 | $1,412.54 |