- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.81 / $1,779.81 / $2,290.04
| Professional | | $1,779.81 | $1,779.81 | $2,290.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.30 / $1,830.30 / $1,830.30
| Professional | | $1,830.30 | $1,830.30 | $1,830.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.73 / $1,584.74 / $2,217.69
| Professional | | $1,491.73 | $1,584.74 | $2,217.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,594.85
| Professional | | $32.34 | $32.34 | $1,594.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.69 / $1,958.42 / $2,217.69
| Professional | | $1,837.69 | $1,958.42 | $2,217.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.85 / $1,336.66 / $2,339.98
| Professional | | $1,046.85 | $1,336.66 | $2,339.98 |