- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.94 / $1,396.88 / $2,136.59
| Professional | | $1,087.94 | $1,396.88 | $2,136.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.96 / $2,074.39 / $4,436.39
| Professional | | $1,200.96 | $2,074.39 | $4,436.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.90 / $2,256.37 / $2,539.15
| Professional | | $1,701.90 | $2,256.37 | $2,539.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.70 / $1,460.76 / $3,471.91
| Professional | | $1,015.70 | $1,460.76 | $3,471.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.74 / $2,050.30 / $4,631.53
| Professional | | $1,235.74 | $2,050.30 | $4,631.53 |