- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.57 / $1,053.57 / $1,114.27
| Professional | | $1,053.57 | $1,053.57 | $1,114.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.00 / $1,598.42 / $3,382.04
| Professional | | $1,356.00 | $1,598.42 | $3,382.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,009.35 / $1,509.58 / $2,022.14
| Professional | | $1,009.35 | $1,509.58 | $2,022.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.46 / $1,338.32 / $2,022.14
| Professional | | $929.46 | $1,338.32 | $2,022.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.56 / $1,270.08 / $3,692.21
| Professional | | $1,102.56 | $1,270.08 | $3,692.21 |