- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $1,000.00
| Professional | | $398.11 | $588.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,071.52 / $1,905.46
| Professional | | $676.08 | $1,071.52 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,412.54 / $2,570.40
| Professional | | $831.76 | $1,412.54 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $2,398.83
| Professional | | $870.96 | $1,318.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,023.29 / $3,630.78
| Professional | | $575.44 | $1,023.29 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $851.14 / $1,778.28
| Professional | | $512.86 | $851.14 | $1,778.28 |