- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.73 / $593.79 / $2,941.64
| Professional | | $545.73 | $593.79 | $2,941.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.37 / $601.37 / $840.00
| Professional | | $601.37 | $601.37 | $840.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.72 / $732.90 / $1,546.64
| Professional | | $513.72 | $732.90 | $1,546.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.77 / $810.56 / $1,328.60
| Professional | | $623.77 | $810.56 | $1,328.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.14 / $713.29 / $1,374.87
| Professional | | $505.14 | $713.29 | $1,374.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.28 / $717.34 / $870.71
| Professional | | $529.28 | $717.34 | $870.71 |