- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.45 / $795.20 / $1,331.65
| Professional | | $675.45 | $795.20 | $1,331.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.00 / $1,284.00 / $1,284.00
| Professional | | $1,284.00 | $1,284.00 | $1,284.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.08 / $1,155.59 / $1,593.34
| Professional | | $786.08 | $1,155.59 | $1,593.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.42 / $1,278.77 / $2,069.60
| Professional | | $852.42 | $1,278.77 | $2,069.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.17 / $1,138.03 / $1,353.00
| Professional | | $529.17 | $1,138.03 | $1,353.00 |