- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $977.24 / $2,238.72
| Professional | | $724.44 | $977.24 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,288.25 / $1,862.09
| Professional | | $794.33 | $1,288.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,202.26 / $1,949.84
| Professional | | $954.99 | $1,202.26 | $1,949.84 |
- 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
- $812.83 / $1,202.26 / $2,398.83
| Professional | | $812.83 | $1,202.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $1,778.28
| Professional | | $741.31 | $1,071.52 | $1,778.28 |