- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $3,090.30
| Professional | | $1,000.00 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,621.81 / $2,344.23
| Professional | | $1,000.00 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $2,454.71
| Professional | | $1,230.27 | $1,584.89 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $2,818.38
| Professional | | $1,230.27 | $1,479.11 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,548.82 / $3,630.78
| Professional | | $1,071.52 | $1,548.82 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,412.54 / $2,344.23
| Professional | | $954.99 | $1,412.54 | $2,344.23 |