- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $2,398.83
| Professional | | $794.33 | $1,000.00 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,288.25 / $1,905.46
| Professional | | $794.33 | $1,288.25 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $2,041.74
| Professional | | $1,000.00 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $2,238.72
| Professional | | $1,000.00 | $1,174.90 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,202.26 / $2,691.53
| Professional | | $870.96 | $1,202.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $1,737.80
| Professional | | $758.58 | $1,148.15 | $1,737.80 |