- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.59 / $2,161.32 / $6,175.77
| Professional | | $882.59 | $2,161.32 | $6,175.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.99 / $2,198.94 / $2,581.69
| Professional | | $1,905.99 | $2,198.94 | $2,581.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.00 / $1,659.28 / $2,942.10
| Professional | | $1,183.00 | $1,659.28 | $2,942.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.53 / $2,272.91 / $2,842.56
| Professional | | $1,568.53 | $2,272.91 | $2,842.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.06 / $2,345.81 / $2,742.07
| Professional | | $1,732.06 | $2,345.81 | $2,742.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.64 / $1,366.01 / $3,078.94
| Professional | | $1,306.64 | $1,366.01 | $3,078.94 |