- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.33 / $1,255.92 / $2,910.29
| Professional | | $1,066.33 | $1,255.92 | $2,910.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.75 / $2,183.92 / $3,017.54
| Professional | | $1,022.75 | $2,183.92 | $3,017.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.96 / $2,149.79 / $3,075.77
| Professional | | $1,517.96 | $2,149.79 | $3,075.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.83 / $1,796.22 / $2,249.53
| Professional | | $982.83 | $1,796.22 | $2,249.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.43 / $2,079.54 / $3,459.16
| Professional | | $1,066.43 | $2,079.54 | $3,459.16 |