- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,000.00 / $2,187.76
| Professional | | $912.01 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Professional | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $2,818.38
| Professional | | $1,698.24 | $1,698.24 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,659.59 / $2,290.87
| Professional | | $1,023.29 | $1,659.59 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $2,454.71
| Professional | | $912.01 | $1,202.26 | $2,454.71 |