- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.03 / $842.24 / $1,351.75
| Professional | | $616.03 | $842.24 | $1,351.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.46 / $1,191.10 / $3,025.23
| Professional | | $1,010.46 | $1,191.10 | $3,025.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.71 / $1,262.10 / $1,446.49
| Professional | | $754.71 | $1,262.10 | $1,446.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $1,156.00 / $1,446.49
| Professional | | $750.00 | $1,156.00 | $1,446.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.86 / $952.32 / $3,279.16
| Professional | | $884.86 | $952.32 | $3,279.16 |