- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.93 / $764.32 / $2,590.00
| Professional | | $710.93 | $764.32 | $2,590.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.97 / $811.97 / $811.97
| Professional | | $811.97 | $811.97 | $811.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.33 / $1,443.14 / $1,712.57
| Professional | | $818.33 | $1,443.14 | $1,712.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.42 / $1,153.45 / $1,712.57
| Professional | | $750.42 | $1,153.45 | $1,712.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.74 / $679.88 / $2,916.18
| Professional | | $424.74 | $679.88 | $2,916.18 |