- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $3,019.95
| Professional | | $912.01 | $1,148.15 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,479.11 / $2,187.76
| Professional | | $1,000.00 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,479.11 / $2,238.72
| Professional | | $1,148.15 | $1,479.11 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $2,754.23
| Professional | | $1,230.27 | $1,479.11 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $3,019.95
| Professional | | $977.24 | $1,318.26 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $2,187.76
| Professional | | $891.25 | $1,318.26 | $2,187.76 |