- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.07 / $874.33 / $1,649.37
| Professional | | $651.07 | $874.33 | $1,649.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.02 / $712.32 / $6,846.00
| Professional | | $685.02 | $712.32 | $6,846.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.92 / $1,104.38 / $2,333.89
| Professional | | $630.92 | $1,104.38 | $2,333.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.94 / $1,852.46 / $1,852.46
| Professional | | $1,395.94 | $1,852.46 | $1,852.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.58 / $1,144.18 / $2,242.83
| Professional | | $656.58 | $1,144.18 | $2,242.83 |