- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $2,630.27
| Professional | | $1,071.52 | $1,348.96 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,630.27
| Professional | | $1,023.29 | $1,513.56 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $2,884.03
| Professional | | $1,348.96 | $1,778.28 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $3,162.28
| Professional | | $2,290.87 | $2,290.87 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $2,398.83
| Professional | | $1,023.29 | $1,412.54 | $2,398.83 |