- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,174.90 / $2,630.27
| Professional | | $977.24 | $1,174.90 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $2,089.30
| Professional | | $912.01 | $1,445.44 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $2,290.87
| Professional | | $1,000.00 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $1,995.26
| Professional | | $1,122.02 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,479.11 / $3,311.31
| Professional | | $1,000.00 | $1,479.11 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $1,995.26
| Professional | | $977.24 | $1,288.25 | $1,995.26 |