- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.83 / $1,355.91 / $2,129.64
| Professional | | $1,115.83 | $1,355.91 | $2,129.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.71 / $3,299.72 / $4,675.97
| Professional | | $2,043.71 | $3,299.72 | $4,675.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,250.81 / $3,660.59 / $5,732.86
| Professional | | $2,250.81 | $3,660.59 | $5,732.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.03 / $3,285.87 / $5,197.80
| Professional | | $2,111.03 | $3,285.87 | $5,197.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,594.69 / $2,859.04 / $13,126.00
| Professional | | $1,594.69 | $2,859.04 | $13,126.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,592.21 / $2,820.30 / $5,327.50
| Professional | | $1,592.21 | $2,820.30 | $5,327.50 |