- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $2,344.23
| Professional | | $758.58 | $977.24 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $1,778.28
| Professional | | $812.83 | $1,230.27 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,230.27 / $1,862.09
| Professional | | $954.99 | $1,230.27 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,202.26 / $2,238.72
| Professional | | $1,000.00 | $1,202.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,148.15 / $2,454.71
| Professional | | $831.76 | $1,148.15 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $1,778.28
| Professional | | $741.31 | $1,047.13 | $1,778.28 |