- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $803.66 / $803.66 / $1,127.19
| Professional | | $803.66 | $803.66 | $1,127.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $565.09 / $739.08 / $4,930.00
| Professional | | $565.09 | $739.08 | $4,930.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.15 / $953.58 / $2,123.62
| Professional | | $649.15 | $953.58 | $2,123.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.25 / $2,176.86 / $2,176.86
| Professional | | $874.25 | $2,176.86 | $2,176.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.78 / $1,163.98 / $2,646.24
| Professional | | $819.78 | $1,163.98 | $2,646.24 |