- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $3,162.28
| Professional | | $1,096.48 | $1,479.11 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,089.30
| Professional | | $1,778.28 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,698.24 / $2,818.38
| Professional | | $933.25 | $1,698.24 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,737.80 / $2,041.74
| Professional | | $1,288.25 | $1,737.80 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,778.28 / $5,128.61
| Professional | | $1,445.44 | $1,778.28 | $5,128.61 |