- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,412.54 / $2,454.71
| Professional | | $741.31 | $1,412.54 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,621.81 / $2,454.71
| Professional | | $1,000.00 | $1,621.81 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,548.82 / $2,454.71
| Professional | | $1,380.38 | $1,548.82 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $2,089.30
| Professional | | $1,348.96 | $1,621.81 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,737.80 / $3,311.31
| Professional | | $1,258.93 | $1,737.80 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $2,089.30
| Professional | | $1,230.27 | $1,621.81 | $2,089.30 |