- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.01 / $1,639.40 / $1,661.55
| Professional | | $1,440.01 | $1,639.40 | $1,661.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.32 / $1,993.86 / $2,412.57
| Professional | | $1,772.32 | $1,993.86 | $2,412.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.16 / $1,174.16 / $1,174.16
| Professional | | $1,174.16 | $1,174.16 | $1,174.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.40 / $2,547.71 / $3,323.10
| Professional | | $2,215.40 | $2,547.71 | $3,323.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $996.93 / $1,794.23
| Professional | | $930.47 | $996.93 | $1,794.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.70 / $1,107.70 / $1,107.70
| Professional | | $1,107.70 | $1,107.70 | $1,107.70 |