- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,737.80
| Professional | | $741.31 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,479.11
| Professional | | $1,174.90 | $1,174.90 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $1,905.46
| Professional | | $912.01 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,479.11 / $10,232.93
| Professional | | $1,023.29 | $1,479.11 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,122.02 / $1,659.59
| Professional | | $891.25 | $1,122.02 | $1,659.59 |