- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,000.00 / $2,344.23
| Professional | | $758.58 | $1,000.00 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,288.25 / $1,862.09
| Professional | | $851.14 | $1,288.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $1,949.84
| Professional | | $977.24 | $1,288.25 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $2,398.83
| Professional | | $1,047.13 | $1,258.93 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $2,570.40
| Professional | | $831.76 | $1,174.90 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $1,862.09
| Professional | | $741.31 | $1,071.52 | $1,862.09 |