- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.82 / $1,352.71 / $6,602.14
| Professional | | $1,092.82 | $1,352.71 | $6,602.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.42 / $2,012.30 / $2,769.98
| Professional | | $1,151.42 | $2,012.30 | $2,769.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.56 / $3,008.60 / $4,436.21
| Professional | | $2,282.56 | $3,008.60 | $4,436.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.60 / $3,218.62 / $8,768.71
| Professional | | $1,897.60 | $3,218.62 | $8,768.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.67 / $3,253.25 / $3,883.26
| Professional | | $2,572.67 | $3,253.25 | $3,883.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.60 / $3,240.51 / $4,087.13
| Professional | | $1,897.60 | $3,240.51 | $4,087.13 |