- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $512.86 / $1,096.48
| Professional | | $380.19 | $512.86 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $676.08 / $1,000.00
| Professional | | $436.52 | $676.08 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $630.96 / $1,047.13
| Professional | | $467.74 | $630.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $1,258.93
| Professional | | $549.54 | $660.69 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $588.84 / $1,348.96
| Professional | | $416.87 | $588.84 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $549.54 / $977.24
| Professional | | $354.81 | $549.54 | $977.24 |