- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.47 / $411.47 / $1,595.66
| Professional | | $411.47 | $411.47 | $1,595.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.19 / $463.46 / $6,701.00
| Professional | | $425.19 | $463.46 | $6,701.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.73 / $1,386.91 / $5,270.00
| Professional | | $504.73 | $1,386.91 | $5,270.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.55 / $3,266.02 / $3,266.02
| Professional | | $1,434.55 | $3,266.02 | $3,266.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.47 / $3,595.00 / $6,256.02
| Professional | | $1,487.47 | $3,595.00 | $6,256.02 |