- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $2,951.21
| Professional | | $1,000.00 | $1,258.93 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,584.89 / $2,511.89
| Professional | | $977.24 | $1,584.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $2,454.71
| Professional | | $1,230.27 | $1,621.81 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $2,754.23
| Professional | | $1,202.26 | $1,479.11 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $3,235.94
| Professional | | $1,148.15 | $1,513.56 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $2,187.76
| Professional | | $1,000.00 | $1,412.54 | $2,187.76 |