- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.15 / $1,000.15 / $1,016.36
| Professional | | $1,000.15 | $1,000.15 | $1,016.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.49 / $1,443.40 / $3,076.01
| Professional | | $1,224.49 | $1,443.40 | $3,076.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.23 / $1,416.48 / $1,918.75
| Professional | | $943.23 | $1,416.48 | $1,918.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.57 / $1,274.22 / $1,918.75
| Professional | | $889.57 | $1,274.22 | $1,918.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.96 / $1,205.13 / $3,503.41
| Professional | | $1,018.96 | $1,205.13 | $3,503.41 |