- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,659.59 / $7,079.46
| Professional | | $1,000.00 | $1,659.59 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,290.87 / $2,754.23
| Professional | | $1,096.48 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $3,311.31
| Professional | | $1,621.81 | $2,290.87 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,187.76 / $3,019.95
| Professional | | $79.43 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,290.87 / $2,951.21
| Professional | | $1,905.46 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $3,467.37
| Professional | | $1,479.11 | $1,737.80 | $3,467.37 |