- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.93 / $756.21 / $1,588.12
| Professional | | $710.93 | $756.21 | $1,588.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.20 / $1,528.07 / $2,701.32
| Professional | | $655.20 | $1,528.07 | $2,701.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.81 / $1,520.60 / $2,281.06
| Professional | | $998.81 | $1,520.60 | $2,281.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.17 / $1,278.64 / $2,631.03
| Professional | | $731.17 | $1,278.64 | $2,631.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.34 / $1,043.77 / $2,224.08
| Professional | | $396.34 | $1,043.77 | $2,224.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.38 / $775.41 / $3,000.00
| Professional | | $574.38 | $775.41 | $3,000.00 |