- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.41 / $2,124.54 / $2,153.25
| Professional | | $1,382.41 | $2,124.54 | $2,153.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,296.80 / $2,296.80 / $2,618.35
| Professional | | $2,296.80 | $2,296.80 | $2,618.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.63 / $2,041.05 / $8,293.14
| Professional | | $1,521.63 | $2,041.05 | $8,293.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,871.00 / $3,445.20 / $4,306.50
| Professional | | $2,871.00 | $3,445.20 | $4,306.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.25 / $1,291.95 / $2,126.78
| Professional | | $893.25 | $1,291.95 | $2,126.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.50 / $2,282.44 / $2,282.44
| Professional | | $1,435.50 | $2,282.44 | $2,282.44 |