- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.33 / $1,240.75 / $1,997.33
| Professional | | $1,066.33 | $1,240.75 | $1,997.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.99 / $1,735.88 / $3,613.10
| Professional | | $1,160.99 | $1,735.88 | $3,613.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.61 / $1,779.68 / $1,798.09
| Professional | | $1,102.61 | $1,779.68 | $1,798.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.77 / $1,427.90 / $3,020.68
| Professional | | $986.77 | $1,427.90 | $3,020.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.42 / $1,448.34 / $3,566.32
| Professional | | $949.42 | $1,448.34 | $3,566.32 |