- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.71 / $1,234.86 / $6,175.75
| Professional | | $1,017.71 | $1,234.86 | $6,175.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.07 / $1,592.70 / $1,811.69
| Professional | | $1,294.07 | $1,592.70 | $1,811.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.36 / $1,577.47 / $2,706.60
| Professional | | $1,115.36 | $1,577.47 | $2,706.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.27 / $1,668.95 / $13,311.20
| Professional | | $1,245.27 | $1,668.95 | $13,311.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.76 / $1,486.68 / $2,751.22
| Professional | | $1,236.76 | $1,486.68 | $2,751.22 |