- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $794.33 / $1,949.84
| Professional | | $588.84 | $794.33 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,230.27 / $1,778.28
| Professional | | $660.69 | $1,230.27 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $2,041.74
| Professional | | $776.25 | $1,230.27 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $1,548.82
| Professional | | $776.25 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,000.00 / $1,949.84
| Professional | | $575.44 | $1,000.00 | $1,949.84 |