- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,096.48 / $1,737.80
| Professional | | $933.25 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $2,089.30
| Professional | | $1,000.00 | $1,412.54 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,737.80 / $2,818.38
| Professional | | $1,288.25 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,630.27
| Professional | | $1,479.11 | $1,737.80 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $1,737.80
| Professional | | $933.25 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,698.24 / $2,630.27
| Professional | | $1,230.27 | $1,698.24 | $2,630.27 |