- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.45 / $987.79 / $1,901.37
| Professional | | $902.45 | $987.79 | $1,901.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,147.00 / $3,147.00 / $3,147.00
| Professional | | $3,147.00 | $3,147.00 | $3,147.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.48 / $1,402.65 / $2,243.50
| Professional | | $1,019.48 | $1,402.65 | $2,243.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.94 / $1,670.62 / $3,574.89
| Professional | | $1,103.94 | $1,670.62 | $3,574.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.23 / $1,241.03 / $1,350.70
| Professional | | $1,201.23 | $1,241.03 | $1,350.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,527.33
| Professional | | $32.34 | $32.34 | $1,527.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.56 / $1,345.44 / $2,460.10
| Professional | | $1,000.56 | $1,345.44 | $2,460.10 |