- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.05 / $1,435.05 / $1,744.06
| Professional | | $1,080.05 | $1,435.05 | $1,744.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.38 / $1,049.18 / $1,867.21
| Professional | | $285.38 | $1,049.18 | $1,867.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.64 / $1,562.03 / $2,469.94
| Professional | | $975.64 | $1,562.03 | $2,469.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.22 / $1,497.69 / $2,207.94
| Professional | | $1,306.22 | $1,497.69 | $2,207.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.00 / $920.81 / $1,544.54
| Professional | | $137.00 | $920.81 | $1,544.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.72 / $1,741.25 / $2,407.62
| Professional | | $1,419.72 | $1,741.25 | $2,407.62 |