- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $758.58 / $2,238.72
| Professional | | $616.60 | $758.58 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,096.48 / $1,288.25
| Professional | | $1,047.13 | $1,096.48 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,047.13 / $3,019.95
| Professional | | $776.25 | $1,047.13 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $1,348.96
| Professional | | $831.76 | $1,047.13 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $1,737.80
| Professional | | $794.33 | $1,096.48 | $1,737.80 |