- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,122.02 / $2,951.21
| Professional | | $891.25 | $1,122.02 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,071.52 / $1,445.44
| Professional | | $954.99 | $1,071.52 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $2,454.71
| Professional | | $933.25 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,000.00 / $1,737.80
| Professional | | $912.01 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,288.25 / $2,290.87
| Professional | | $933.25 | $1,288.25 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,096.48 / $1,380.38
| Professional | | $954.99 | $1,096.48 | $1,380.38 |