- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.40 / $737.29 / $1,346.82
| Professional | | $518.40 | $737.29 | $1,346.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.14 / $1,745.18 / $2,287.63
| Professional | | $1,094.14 | $1,745.18 | $2,287.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.80 / $1,628.08 / $10,000.00
| Professional | | $758.80 | $1,628.08 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.88 / $1,602.13 / $2,111.90
| Professional | | $1,238.88 | $1,602.13 | $2,111.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.30 / $1,179.95 / $1,531.21
| Professional | | $834.30 | $1,179.95 | $1,531.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.63 / $1,460.56 / $2,271.98
| Professional | | $704.63 | $1,460.56 | $2,271.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.59 / $1,432.20 / $1,858.60
| Professional | | $1,170.59 | $1,432.20 | $1,858.60 |