- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.70 / $1,590.28 / $2,013.52
| Professional | | $1,206.70 | $1,590.28 | $2,013.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.81 / $1,922.11 / $3,157.75
| Professional | | $347.81 | $1,922.11 | $3,157.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.08 / $1,767.12 / $2,718.52
| Professional | | $1,125.08 | $1,767.12 | $2,718.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.17 / $1,722.93 / $2,514.82
| Professional | | $1,446.17 | $1,722.93 | $2,514.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.00 / $1,076.95 / $1,781.93
| Professional | | $137.00 | $1,076.95 | $1,781.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.29 / $1,983.05 / $2,820.34
| Professional | | $1,487.29 | $1,983.05 | $2,820.34 |