- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $831.76 / $1,949.84
| Professional | | $602.56 | $831.76 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,071.52 / $1,548.82
| Professional | | $676.08 | $1,071.52 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,621.81
| Professional | | $741.31 | $1,000.00 | $1,621.81 |
- 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 / $1,000.00 / $2,041.74
| Professional | | $645.65 | $1,000.00 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $851.14 / $1,479.11
| Professional | | $616.60 | $851.14 | $1,479.11 |