- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $2,089.30
| Professional | | $812.83 | $1,071.52 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,348.96 / $1,778.28
| Professional | | $794.33 | $1,348.96 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $2,089.30
| Professional | | $1,000.00 | $1,230.27 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,318.26 / $1,862.09
| Professional | | $1,096.48 | $1,318.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $2,630.27
| Professional | | $812.83 | $1,288.25 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,258.93 / $2,089.30
| Professional | | $851.14 | $1,258.93 | $2,089.30 |