- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,584.89
| Professional | | $776.25 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $3,388.44
| Professional | | $1,380.38 | $2,089.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,691.53 / $4,168.69
| Professional | | $1,584.89 | $2,691.53 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,454.71 / $3,981.07
| Professional | | $1,659.59 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,089.30 / $10,232.93
| Professional | | $977.24 | $2,089.30 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,737.80 / $3,235.94
| Professional | | $912.01 | $1,737.80 | $3,235.94 |