- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,000.00 / $1,412.54
| Professional | | $575.44 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,148.15 / $1,737.80
| Professional | | $707.95 | $1,148.15 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,174.90 / $1,737.80
| Professional | | $1,023.29 | $1,174.90 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,479.11
| Professional | | $933.25 | $1,122.02 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $2,089.30
| Professional | | $812.83 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,548.82
| Professional | | $933.25 | $1,202.26 | $1,548.82 |