- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.92 / $1,246.47 / $1,886.24
| Professional | | $1,047.92 | $1,246.47 | $1,886.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.69 / $1,774.71 / $2,303.44
| Professional | | $1,153.69 | $1,774.71 | $2,303.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,787.54
| Professional | | $32.34 | $32.34 | $1,787.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.92 / $1,897.10 / $2,987.58
| Professional | | $1,220.92 | $1,897.10 | $2,987.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.33 / $1,776.24 / $2,809.89
| Professional | | $1,317.33 | $1,776.24 | $2,809.89 |