- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $794.33 / $1,258.93
| Professional | | $676.08 | $794.33 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,000.00 / $1,479.11
| Professional | | $707.95 | $1,000.00 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $2,041.74
| Professional | | $933.25 | $1,258.93 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,258.93 / $1,905.46
| Professional | | $1,071.52 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $724.44 / $1,258.93
| Professional | | $676.08 | $724.44 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $1,905.46
| Professional | | $891.25 | $1,230.27 | $1,905.46 |