- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.59 / $1,485.85 / $3,074.57
| Professional | | $1,200.59 | $1,485.85 | $3,074.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.87 / $1,733.19 / $2,951.14
| Professional | | $983.87 | $1,733.19 | $2,951.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,358.87 / $2,093.50 / $2,790.76
| Professional | | $1,358.87 | $2,093.50 | $2,790.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $248.47 / $2,070.60
| Professional | | $32.34 | $248.47 | $2,070.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.97 / $2,174.19 / $3,086.52
| Professional | | $1,511.97 | $2,174.19 | $3,086.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,709.30 / $2,286.56 / $3,530.79
| Professional | | $1,709.30 | $2,286.56 | $3,530.79 |