- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $776.25 / $1,778.28
| Professional | | $575.44 | $776.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,000.00 / $1,445.44
| Professional | | $660.69 | $1,000.00 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $1,513.56
| Professional | | $758.58 | $1,000.00 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,000.00 / $1,905.46
| Professional | | $831.76 | $1,000.00 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $2,041.74
| Professional | | $645.65 | $912.01 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $831.76 / $1,479.11
| Professional | | $562.34 | $831.76 | $1,479.11 |