- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $891.25 / $1,445.44
| Professional | | $676.08 | $891.25 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $630.96 / $676.08
| Professional | | $537.03 | $630.96 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,047.13 / $2,818.38
| Professional | | $724.44 | $1,047.13 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $794.33 / $5,754.40
| Professional | | $398.11 | $794.33 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $776.25 / $1,148.15
| Professional | | $363.08 | $776.25 | $1,148.15 |