- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $2,754.23
| Professional | | $1,000.00 | $1,348.96 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $1,949.84
| Professional | | $1,659.59 | $1,659.59 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,513.56 / $2,454.71
| Professional | | $954.99 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $1,819.70
| Professional | | $1,148.15 | $1,548.82 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $2,630.27
| Professional | | $1,288.25 | $1,548.82 | $2,630.27 |