- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.27 / $1,135.43 / $4,844.00
| Professional | | $889.27 | $1,135.43 | $4,844.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.22 / $1,667.67 / $2,084.59
| Professional | | $1,010.22 | $1,667.67 | $2,084.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,507.64
| Professional | | $32.34 | $32.34 | $1,507.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.05 / $1,727.23 / $2,374.63
| Professional | | $1,053.05 | $1,727.23 | $2,374.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.11 / $1,707.58 / $2,584.79
| Professional | | $1,185.11 | $1,707.58 | $2,584.79 |