- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $851.14 / $1,905.46
| Professional | | $616.60 | $851.14 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,288.25
| Professional | | $1,096.48 | $1,096.48 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,023.29 / $1,621.81
| Professional | | $616.60 | $1,023.29 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,258.93
| Professional | | $758.58 | $977.24 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $3,019.95
| Professional | | $891.25 | $1,023.29 | $3,019.95 |