- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.44 / $1,343.71 / $1,883.03
| Professional | | $1,040.44 | $1,343.71 | $1,883.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.28 / $2,347.62 / $3,706.62
| Professional | | $2,201.28 | $2,347.62 | $3,706.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.74 / $1,724.96 / $2,938.09
| Professional | | $1,220.74 | $1,724.96 | $2,938.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.10 / $1,595.45 / $2,938.09
| Professional | | $1,077.10 | $1,595.45 | $2,938.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.83 / $1,644.87 / $4,274.78
| Professional | | $1,241.83 | $1,644.87 | $4,274.78 |