- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $2,137.96
| Professional | | $776.25 | $1,000.00 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,318.26 / $1,949.84
| Professional | | $851.14 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,202.26 / $1,995.26
| Professional | | $851.14 | $1,202.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,412.54 / $2,630.27
| Professional | | $1,174.90 | $1,412.54 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $2,884.03
| Professional | | $794.33 | $1,122.02 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,148.15 / $2,089.30
| Professional | | $724.44 | $1,148.15 | $2,089.30 |