- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.38 / $1,396.88 / $2,220.65
| Professional | | $1,028.38 | $1,396.88 | $2,220.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.88 / $1,887.55 / $2,905.69
| Professional | | $1,315.88 | $1,887.55 | $2,905.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.01 / $1,924.36 / $3,099.63
| Professional | | $1,341.01 | $1,924.36 | $3,099.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,323.28 / $10,709.20 / $12,198.38
| Professional | | $8,323.28 | $10,709.20 | $12,198.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.65 / $1,854.05 / $3,201.56
| Professional | | $1,324.65 | $1,854.05 | $3,201.56 |