- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.74 / $2,189.69 / $2,189.69
| Professional | | $1,897.74 | $2,189.69 | $2,189.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,335.67 / $2,686.03 / $3,062.07
| Professional | | $2,335.67 | $2,686.03 | $3,062.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.39 / $1,547.39 / $1,547.39
| Professional | | $1,547.39 | $1,547.39 | $1,547.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,919.60 / $3,357.54 / $4,379.39
| Professional | | $2,919.60 | $3,357.54 | $4,379.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,393.82 / $2,364.55
| Professional | | $1,226.23 | $1,393.82 | $2,364.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.80 / $1,459.80 / $1,459.80
| Professional | | $1,459.80 | $1,459.80 | $1,459.80 |