- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,318.26 / $3,162.28
| Professional | | $1,047.13 | $1,318.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,737.80 / $2,454.71
| Professional | | $1,047.13 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $2,570.40
| Professional | | $1,230.27 | $1,479.11 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,548.82 / $2,951.21
| Professional | | $1,288.25 | $1,548.82 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $3,467.37
| Professional | | $1,148.15 | $1,548.82 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,513.56 / $2,454.71
| Professional | | $1,000.00 | $1,513.56 | $2,454.71 |