- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $2,691.53 / $6,309.57
| Professional | | $724.44 | $2,691.53 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,398.83 / $8,317.64
| Professional | | $1,000.00 | $2,398.83 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $2,344.23 / $6,760.83
| Professional | | $870.96 | $2,344.23 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28,183.83 / $33,113.11 / $33,113.11
| Professional | | $28,183.83 | $33,113.11 | $33,113.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,187.76 / $6,606.93
| Professional | | $776.25 | $2,187.76 | $6,606.93 |