- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $1,819.70
| Professional | | $851.14 | $1,000.00 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,311.31
| Professional | | $1,288.25 | $1,288.25 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,318.26 / $3,801.89
| Professional | | $707.95 | $1,318.26 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $2,398.83
| Professional | | $977.24 | $1,318.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $2,511.89
| Professional | | $977.24 | $1,288.25 | $2,511.89 |