- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $2,398.83
| Professional | | $776.25 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,258.93 / $1,862.09
| Professional | | $794.33 | $1,258.93 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $1,949.84
| Professional | | $977.24 | $1,230.27 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,174.90 / $2,238.72
| Professional | | $977.24 | $1,174.90 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,202.26 / $2,454.71
| Professional | | $870.96 | $1,202.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $1,905.46
| Professional | | $758.58 | $1,122.02 | $1,905.46 |