- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.77 / $2,138.55 / $5,687.71
| Professional | | $1,426.77 | $2,138.55 | $5,687.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.44 / $2,255.26 / $2,577.77
| Professional | | $2,064.44 | $2,255.26 | $2,577.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.78 / $2,056.33 / $4,381.54
| Professional | | $1,541.78 | $2,056.33 | $4,381.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.09 / $2,298.90 / $3,810.56
| Professional | | $1,782.09 | $2,298.90 | $3,810.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.44 / $1,927.19 / $3,313.52
| Professional | | $1,403.44 | $1,927.19 | $3,313.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.41 / $1,406.41 / $2,499.44
| Professional | | $1,406.41 | $1,406.41 | $2,499.44 |