- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $478.63 / $1,122.02
| Professional | | $346.74 | $478.63 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $616.60 / $870.96
| Professional | | $398.11 | $616.60 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $676.08 / $1,202.26
| Professional | | $478.63 | $676.08 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $645.65 / $1,000.00
| Professional | | $457.09 | $645.65 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $562.34 / $1,513.56
| Professional | | $363.08 | $562.34 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $660.69 / $1,096.48
| Professional | | $457.09 | $660.69 | $1,096.48 |