- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.46 / $1,310.08 / $2,010.65
| Professional | | $1,089.46 | $1,310.08 | $2,010.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.91 / $1,698.08 / $2,787.82
| Professional | | $1,094.91 | $1,698.08 | $2,787.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.42 / $1,846.70 / $2,919.62
| Professional | | $1,426.42 | $1,846.70 | $2,919.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,851.65 / $3,851.65 / $3,851.65
| Professional | | $3,851.65 | $3,851.65 | $3,851.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.60 / $972.62 / $1,771.54
| Professional | | $150.60 | $972.62 | $1,771.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.78 / $1,595.44 / $2,961.90
| Professional | | $1,159.78 | $1,595.44 | $2,961.90 |