- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,737.80
| Professional | | $776.25 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,122.02 / $1,659.59
| Professional | | $812.83 | $1,122.02 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $1,737.80
| Professional | | $831.76 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.49 / $1,122.02 / $2,691.53
| Professional | | $13.49 | $1,122.02 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $4,786.30
| Professional | | $1,071.52 | $1,513.56 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,023.29 / $1,778.28
| Professional | | $724.44 | $1,023.29 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,621.81
| Professional | | $794.33 | $1,071.52 | $1,621.81 |