- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $501.19 / $1,096.48
| Professional | | $398.11 | $501.19 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $645.65 / $933.25
| Professional | | $416.87 | $645.65 | $933.25 |
- 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
- $524.81 / $676.08 / $1,348.96
| Professional | | $524.81 | $676.08 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $1,380.38
| Professional | | $426.58 | $602.56 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $575.44 / $1,023.29
| Professional | | $380.19 | $575.44 | $1,023.29 |