- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.58 / $1,500.06 / $1,981.30
| Professional | | $1,196.58 | $1,500.06 | $1,981.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.99 / $1,528.10 / $2,964.21
| Professional | | $1,142.99 | $1,528.10 | $2,964.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,614.98 / $2,167.77 / $3,261.09
| Professional | | $1,614.98 | $2,167.77 | $3,261.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.48 / $1,105.48 / $1,105.48
| Professional | | $1,105.48 | $1,105.48 | $1,105.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.60 / $1,134.45 / $2,060.68
| Professional | | $150.60 | $1,134.45 | $2,060.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.03 / $1,794.71 / $2,916.24
| Professional | | $1,322.03 | $1,794.71 | $2,916.24 |