- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.15 / $1,693.72 / $4,142.43
| Professional | | $1,129.15 | $1,693.72 | $4,142.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,996.59 / $1,996.59 / $1,996.59
| Professional | | $1,996.59 | $1,996.59 | $1,996.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.46 / $1,898.74 / $2,303.01
| Professional | | $1,566.46 | $1,898.74 | $2,303.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,673.33
| Professional | | $32.34 | $32.34 | $1,673.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,909.45 / $2,044.73 / $2,303.01
| Professional | | $1,909.45 | $2,044.73 | $2,303.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.80 / $1,995.03 / $2,801.55
| Professional | | $1,295.80 | $1,995.03 | $2,801.55 |