- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.17 / $444.27 / $540.20
| Professional | | $357.17 | $444.27 | $540.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.69 / $959.88 / $1,339.56
| Professional | | $741.69 | $959.88 | $1,339.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.90 / $979.77 / $1,418.70
| Professional | | $576.90 | $979.77 | $1,418.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.26 / $974.20 / $2,800.00
| Professional | | $540.26 | $974.20 | $2,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.26 / $956.26 / $1,188.57
| Professional | | $540.26 | $956.26 | $1,188.57 |