- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $2,454.71
| Professional | | $1,174.90 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,862.09 / $3,162.28
| Professional | | $1,148.15 | $1,862.09 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $1,905.46
| Professional | | $912.01 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $933.25 / $2,137.96
| Professional | | $32.36 | $933.25 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,548.82 / $2,754.23
| Professional | | $1,071.52 | $1,548.82 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,621.81
| Professional | | $933.25 | $1,202.26 | $1,621.81 |