- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $6,606.93
| Professional | | $1,047.13 | $1,230.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $2,951.21
| Professional | | $1,905.46 | $2,398.83 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,778.28 / $2,884.03
| Professional | | $1,047.13 | $1,778.28 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,905.46 / $2,238.72
| Professional | | $1,380.38 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,862.09 / $2,754.23
| Professional | | $1,202.26 | $1,862.09 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,137.96 / $2,137.96
| Professional | | $1,819.70 | $2,137.96 | $2,137.96 |