- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.40 / $1,244.24 / $6,175.75
| Professional | | $1,035.40 | $1,244.24 | $6,175.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.38 / $1,862.01 / $2,532.23
| Professional | | $1,092.38 | $1,862.01 | $2,532.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,072.42 / $2,836.61 / $3,858.49
| Professional | | $2,072.42 | $2,836.61 | $3,858.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.16 / $2,938.84 / $13,126.00
| Professional | | $1,743.16 | $2,938.84 | $13,126.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,165.53 / $2,938.84 / $3,657.42
| Professional | | $2,165.53 | $2,938.84 | $3,657.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.16 / $2,882.91 / $3,754.49
| Professional | | $1,743.16 | $2,882.91 | $3,754.49 |