- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.61 / $1,176.33 / $5,565.85
| Professional | | $1,105.61 | $1,176.33 | $5,565.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.70 / $1,208.70 / $1,547.14
| Professional | | $1,208.70 | $1,208.70 | $1,547.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.43 / $1,412.88 / $3,461.33
| Professional | | $1,079.43 | $1,412.88 | $3,461.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.71 / $1,483.89 / $2,403.48
| Professional | | $1,115.71 | $1,483.89 | $2,403.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.37 / $1,310.63 / $2,556.50
| Professional | | $943.37 | $1,310.63 | $2,556.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.28 / $1,283.07 / $1,583.22
| Professional | | $824.28 | $1,283.07 | $1,583.22 |