- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.59 / $975.90 / $1,708.16
| Professional | | $638.59 | $975.90 | $1,708.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,310.00 / $2,310.00
| Professional | | $2,100.00 | $2,310.00 | $2,310.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $742.34
| Professional | | $742.34 | $742.34 | $742.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,087.28 / $2,087.28 / $2,087.28
| Professional | | $2,087.28 | $2,087.28 | $2,087.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.97 / $771.56 / $1,223.68
| Professional | | $642.97 | $771.56 | $1,223.68 |