- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $870.96 / $1,862.09
| Professional | | $645.65 | $870.96 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,258.93
| Professional | | $1,071.52 | $1,071.52 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,000.00 / $1,659.59
| Professional | | $616.60 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,230.27
| Professional | | $758.58 | $1,023.29 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,047.13 / $3,019.95
| Professional | | $851.14 | $1,047.13 | $3,019.95 |