- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.30 / $1,007.30 / $1,007.30
| Professional | | $1,007.30 | $1,007.30 | $1,007.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.83 / $1,363.40 / $2,069.19
| Professional | | $1,164.83 | $1,363.40 | $2,069.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.59 / $1,755.69 / $2,713.19
| Professional | | $975.59 | $1,755.69 | $2,713.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,569.25 / $1,880.12 / $2,785.26
| Professional | | $1,569.25 | $1,880.12 | $2,785.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.30 / $1,007.30 / $1,007.30
| Professional | | $1,007.30 | $1,007.30 | $1,007.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.83 / $1,731.02 / $2,501.16
| Professional | | $1,223.83 | $1,731.02 | $2,501.16 |