- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.56 / $1,152.65 / $4,492.22
| Professional | | $1,033.56 | $1,152.65 | $4,492.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.83 / $1,140.83 / $1,460.28
| Professional | | $1,140.83 | $1,140.83 | $1,460.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.42 / $1,338.00 / $2,682.50
| Professional | | $905.42 | $1,338.00 | $2,682.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.89 / $1,431.76 / $2,320.53
| Professional | | $1,109.89 | $1,431.76 | $2,320.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.23 / $1,159.14 / $2,248.73
| Professional | | $760.23 | $1,159.14 | $2,248.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.69 / $1,276.36 / $1,531.35
| Professional | | $844.69 | $1,276.36 | $1,531.35 |