- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $2,951.21
| Professional | | $1,000.00 | $1,288.25 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,445.44
| Professional | | $1,071.52 | $1,202.26 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Facility | | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,479.11 / $2,951.21
| Professional | | $1,000.00 | $1,479.11 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,380.38 / $2,041.74
| Professional | | $1,202.26 | $1,380.38 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,344.23
| Professional | | $933.25 | $1,318.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,513.56 / $1,819.70
| Professional | | $1,000.00 | $1,513.56 | $1,819.70 |