- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.27 / $1,235.90 / $1,617.02
| Professional | | $1,079.27 | $1,235.90 | $1,617.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.88 / $1,327.73 / $2,162.92
| Professional | | $1,073.88 | $1,327.73 | $2,162.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.72 / $1,640.45 / $2,666.42
| Professional | | $1,353.72 | $1,640.45 | $2,666.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.57 / $802.26 / $1,489.72
| Professional | | $113.57 | $802.26 | $1,489.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.56 / $1,366.67 / $2,564.85
| Professional | | $1,001.56 | $1,366.67 | $2,564.85 |