- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $2,570.40
| Professional | | $758.58 | $977.24 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,348.96 / $2,951.21
| Professional | | $794.33 | $1,348.96 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,258.93 / $1,737.80
| Professional | | $870.96 | $1,258.93 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,174.90 / $3,801.89
| Professional | | $660.69 | $1,174.90 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,000.00 / $2,454.71
| Professional | | $676.08 | $1,000.00 | $2,454.71 |