- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $562.34 / $1,148.15
| Professional | | $416.87 | $562.34 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $676.08 / $1,000.00
| Professional | | $446.68 | $676.08 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $691.83 / $1,071.52
| Professional | | $489.78 | $691.83 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $724.44 / $1,445.44
| Professional | | $549.54 | $724.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $630.96 / $1,348.96
| Professional | | $426.58 | $630.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $602.56 / $1,096.48
| Professional | | $398.11 | $602.56 | $1,096.48 |