- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.38 / $1,206.59 / $2,774.27
| Professional | | $1,080.38 | $1,206.59 | $2,774.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.77 / $1,172.77 / $1,340.47
| Professional | | $1,172.77 | $1,172.77 | $1,340.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.62 / $1,425.18 / $4,854.34
| Professional | | $936.62 | $1,425.18 | $4,854.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.77 / $1,290.99 / $2,132.11
| Professional | | $1,000.77 | $1,290.99 | $2,132.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.69 / $1,132.17 / $1,974.62
| Professional | | $834.69 | $1,132.17 | $1,974.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.29 / $714.29 / $1,436.13
| Professional | | $714.29 | $714.29 | $1,436.13 |