- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.92 / $575.46 / $2,490.34
| Professional | | $369.92 | $575.46 | $2,490.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.46 / $962.94 / $1,693.40
| Professional | | $717.46 | $962.94 | $1,693.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.63 / $1,213.95 / $1,562.34
| Professional | | $1,011.63 | $1,213.95 | $1,562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $994.98 / $1,751.20 / $2,334.50
| Professional | | $994.98 | $1,751.20 | $2,334.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.42 / $1,486.75 / $2,848.86
| Professional | | $738.42 | $1,486.75 | $2,848.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.44 / $1,354.72 / $2,043.74
| Professional | | $584.44 | $1,354.72 | $2,043.74 |