- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.33 / $1,577.27 / $2,006.74
| Professional | | $1,249.33 | $1,577.27 | $2,006.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.65 / $1,815.27 / $3,096.56
| Professional | | $1,012.65 | $1,815.27 | $3,096.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.89 / $2,151.60 / $2,890.94
| Professional | | $1,390.89 | $2,151.60 | $2,890.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $261.83 / $2,182.00
| Professional | | $32.34 | $261.83 | $2,182.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.30 / $2,234.00 / $3,208.45
| Professional | | $1,572.30 | $2,234.00 | $3,208.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,771.21 / $2,503.33 / $3,708.98
| Professional | | $1,771.21 | $2,503.33 | $3,708.98 |