- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $2,398.83
| Professional | | $812.83 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $1,905.46
| Professional | | $812.83 | $1,288.25 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $1,995.26
| Professional | | $977.24 | $1,230.27 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $2,290.87
| Professional | | $1,023.29 | $1,230.27 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,122.02 / $2,454.71
| Professional | | $851.14 | $1,122.02 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $1,905.46
| Professional | | $758.58 | $1,148.15 | $1,905.46 |