- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $794.33 / $1,479.11
| Professional | | $562.34 | $794.33 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,148.15 / $2,691.53
| Professional | | $977.24 | $1,148.15 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,000.00 / $1,288.25
| Professional | | $602.56 | $1,000.00 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $2,691.53
| Professional | | $1,230.27 | $1,230.27 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $851.14 / $2,454.71
| Professional | | $616.60 | $851.14 | $2,454.71 |