- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,380.38 / $2,398.83
| Professional | | $741.31 | $1,380.38 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,584.89 / $2,398.83
| Professional | | $1,000.00 | $1,584.89 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,548.82 / $2,398.83
| Professional | | $1,380.38 | $1,548.82 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $1,995.26
| Professional | | $1,288.25 | $1,548.82 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,698.24 / $3,548.13
| Professional | | $1,258.93 | $1,698.24 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $2,089.30
| Professional | | $1,288.25 | $1,621.81 | $2,089.30 |