- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.29 / $745.05 / $2,716.76
| Professional | | $389.29 | $745.05 | $2,716.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.42 / $787.16 / $2,682.95
| Professional | | $455.42 | $787.16 | $2,682.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.89 / $2,093.57 / $3,119.86
| Professional | | $517.89 | $2,093.57 | $3,119.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.50 / $1,099.05 / $3,075.43
| Professional | | $476.50 | $1,099.05 | $3,075.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.74 / $717.46 / $2,905.35
| Professional | | $405.74 | $717.46 | $2,905.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.16 / $2,496.02 / $3,392.30
| Professional | | $1,866.16 | $2,496.02 | $3,392.30 |