- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,862.09 / $3,311.31
| Professional | | $1,000.00 | $1,862.09 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $3,311.31
| Professional | | $1,348.96 | $2,187.76 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $3,311.31
| Professional | | $1,819.70 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $2,754.23
| Professional | | $1,737.80 | $2,089.30 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $4,570.88
| Professional | | $1,698.24 | $2,290.87 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,187.76 / $2,818.38
| Professional | | $1,621.81 | $2,187.76 | $2,818.38 |