- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $2,454.71
| Professional | | $912.01 | $1,071.52 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,659.59 / $3,235.94
| Professional | | $1,000.00 | $1,659.59 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $275.42
| Professional | | $32.36 | $33.11 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,698.24 / $2,238.72
| Professional | | $1,023.29 | $1,698.24 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,621.81 / $2,238.72
| Professional | | $1,122.02 | $1,621.81 | $2,238.72 |