- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $616.60 / $1,174.90
| Professional | | $446.68 | $616.60 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $758.58 / $1,000.00
| Professional | | $436.52 | $758.58 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $676.08 / $1,174.90
| Professional | | $512.86 | $676.08 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $707.95 / $1,047.13
| Professional | | $588.84 | $707.95 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $616.60 / $1,412.54
| Professional | | $457.09 | $616.60 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $691.83 / $1,148.15
| Professional | | $478.63 | $691.83 | $1,148.15 |