- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,000.00 / $1,288.25
| Professional | | $870.96 | $1,000.00 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,513.56
| Professional | | $1,258.93 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,258.93 / $2,137.96
| Professional | | $724.44 | $1,258.93 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $1,584.89
| Professional | | $1,000.00 | $1,318.26 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $3,890.45
| Professional | | $1,071.52 | $1,348.96 | $3,890.45 |