- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.71 / $1,296.46 / $1,800.59
| Professional | | $1,106.71 | $1,296.46 | $1,800.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.76 / $1,378.32 / $1,973.20
| Professional | | $1,167.76 | $1,378.32 | $1,973.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.14 / $1,555.02 / $2,481.41
| Professional | | $1,213.14 | $1,555.02 | $2,481.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.00 / $1,984.19 / $3,072.59
| Professional | | $1,365.00 | $1,984.19 | $3,072.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $812.70 / $1,495.23
| Professional | | $32.34 | $812.70 | $1,495.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.39 / $2,091.46 / $3,075.75
| Professional | | $1,470.39 | $2,091.46 | $3,075.75 |