- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $5,248.07
| Professional | | $891.25 | $1,288.25 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,513.56 / $2,089.30
| Professional | | $891.25 | $1,513.56 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $2,754.23
| Professional | | $32.36 | $33.11 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,949.84 / $3,162.28
| Professional | | $1,230.27 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,778.28 / $2,754.23
| Professional | | $870.96 | $1,778.28 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $2,238.72
| Professional | | $1,202.26 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $1,862.09
| Professional | | $912.01 | $1,202.26 | $1,862.09 |