- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.48 / $731.00 / $1,215.08
| Professional | | $521.48 | $731.00 | $1,215.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.82 / $1,143.82 / $3,741.15
| Professional | | $1,143.82 | $1,143.82 | $3,741.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.49 / $1,135.13 / $2,411.98
| Professional | | $793.49 | $1,135.13 | $2,411.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.16 / $1,153.75 / $2,411.98
| Professional | | $806.16 | $1,153.75 | $2,411.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.94 / $1,404.60 / $4,404.04
| Professional | | $985.94 | $1,404.60 | $4,404.04 |