- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $1,862.09
| Professional | | $660.69 | $870.96 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,318.26
| Professional | | $1,122.02 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,000.00 / $1,659.59
| Professional | | $645.65 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,202.26
| Professional | | $758.58 | $1,023.29 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,023.29 / $3,019.95
| Professional | | $851.14 | $1,023.29 | $3,019.95 |