- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $3,388.44
| Professional | | $933.25 | $1,258.93 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,041.74 / $3,019.95
| Professional | | $1,000.00 | $2,041.74 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,884.03
| Professional | | $1,318.26 | $1,862.09 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,621.81 / $2,041.74
| Professional | | $933.25 | $1,621.81 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,548.82 / $2,884.03
| Professional | | $933.25 | $1,548.82 | $2,884.03 |