- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $758.58 / $1,862.09
| Professional | | $524.81 | $758.58 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,000.00 / $1,995.26
| Professional | | $851.14 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $851.14 / $1,023.29
| Professional | | $512.86 | $851.14 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,995.26
| Professional | | $933.25 | $933.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $758.58 / $2,290.87
| Professional | | $549.54 | $758.58 | $2,290.87 |