- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $524.81 / $1,122.02
| Professional | | $416.87 | $524.81 | $1,122.02 |
- 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
- $501.19 / $645.65 / $1,047.13
| Professional | | $501.19 | $645.65 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $1,230.27
| Professional | | $549.54 | $660.69 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $575.44 / $1,348.96
| Professional | | $416.87 | $575.44 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $977.24
| Professional | | $389.05 | $562.34 | $977.24 |