- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $812.83 / $1,778.28
| Professional | | $588.84 | $812.83 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,071.52 / $1,513.56
| Professional | | $724.44 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,096.48 / $1,778.28
| Professional | | $776.25 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $1,621.81
| Professional | | $912.01 | $1,047.13 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,000.00 / $2,570.40
| Professional | | $602.56 | $1,000.00 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $1,584.89
| Professional | | $758.58 | $1,047.13 | $1,584.89 |