- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $3,715.35
| Professional | | $933.25 | $1,000.00 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,548.82 / $2,238.72
| Professional | | $933.25 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,238.72 / $2,951.21
| Professional | | $1,202.26 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,995.26 / $9,120.11
| Professional | | $1,096.48 | $1,995.26 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,570.40 / $3,162.28
| Professional | | $1,949.84 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,290.87 / $3,090.30
| Professional | | $2,238.72 | $2,290.87 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,905.46 / $2,818.38
| Professional | | $1,096.48 | $1,905.46 | $2,818.38 |