- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.13 / $2,062.98 / $2,837.73
| Professional | | $1,427.13 | $2,062.98 | $2,837.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.40 / $2,797.60 / $2,797.60
| Professional | | $2,078.40 | $2,797.60 | $2,797.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $1,472.88
| Professional | | $192.51 | $1,472.88 | $1,472.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.47 / $1,867.96 / $2,484.39
| Professional | | $1,584.47 | $1,867.96 | $2,484.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.91 / $340.03 / $2,074.44
| Professional | | $154.91 | $340.03 | $2,074.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.98 / $2,496.60 / $2,496.60
| Professional | | $1,751.98 | $2,496.60 | $2,496.60 |