- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $2,290.87
| Professional | | $1,096.48 | $1,380.38 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,584.89 / $2,454.71
| Professional | | $1,148.15 | $1,584.89 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,659.59 / $2,454.71
| Professional | | $1,174.90 | $1,659.59 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $1,621.81 / $2,691.53
| Professional | | $16.22 | $1,621.81 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,089.30 / $4,786.30
| Professional | | $1,513.56 | $2,089.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $2,454.71
| Professional | | $1,000.00 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $2,290.87
| Professional | | $1,122.02 | $1,513.56 | $2,290.87 |