- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $977.24 / $2,290.87
| Professional | | $794.33 | $977.24 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $1,862.09
| Professional | | $812.83 | $1,288.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,949.84
| Professional | | $933.25 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $2,290.87
| Professional | | $1,000.00 | $1,202.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $2,454.71
| Professional | | $831.76 | $1,202.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,122.02 / $1,862.09
| Professional | | $741.31 | $1,122.02 | $1,862.09 |