- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.62 / $2,378.19 / $2,616.01
| Professional | | $2,306.62 | $2,378.19 | $2,616.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.00 / $1,229.58 / $1,615.67
| Professional | | $799.00 | $1,229.58 | $1,615.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.34 / $1,884.11 / $3,038.08
| Professional | | $1,121.34 | $1,884.11 | $3,038.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.60 / $1,464.09 / $2,118.33
| Professional | | $1,134.60 | $1,464.09 | $2,118.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.48 / $1,033.45 / $1,981.00
| Professional | | $67.48 | $1,033.45 | $1,981.00 |