- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $758.58 / $1,995.26
| Professional | | $602.56 | $758.58 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $977.24 / $1,318.26
| Professional | | $562.34 | $977.24 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $912.01 / $1,548.82
| Professional | | $724.44 | $912.01 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $954.99 / $1,412.54
| Professional | | $776.25 | $954.99 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $1,995.26
| Professional | | $660.69 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $977.24 / $1,548.82
| Professional | | $660.69 | $977.24 | $1,548.82 |