- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $2,884.03
| Professional | | $933.25 | $1,122.02 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,238.72 / $2,238.72
| Professional | | $891.25 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,318.26 / $2,951.21
| Professional | | $758.58 | $1,318.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $2,089.30
| Professional | | $933.25 | $1,202.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,202.26 / $1,778.28
| Professional | | $741.31 | $1,202.26 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $1,698.24
| Professional | | $1,000.00 | $1,288.25 | $1,698.24 |