- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.51 / $1,323.77 / $6,267.23
| Professional | | $1,038.51 | $1,323.77 | $6,267.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.76 / $1,940.17 / $2,729.19
| Professional | | $1,099.76 | $1,940.17 | $2,729.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,180.14 / $3,208.12 / $4,323.58
| Professional | | $2,180.14 | $3,208.12 | $4,323.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.86 / $3,129.16 / $8,373.92
| Professional | | $1,844.86 | $3,129.16 | $8,373.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,449.00 / $3,208.12 / $3,781.26
| Professional | | $2,449.00 | $3,208.12 | $3,781.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.86 / $3,150.45 / $3,973.54
| Professional | | $1,844.86 | $3,150.45 | $3,973.54 |