- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.34 / $1,085.45 / $5,192.10
| Professional | | $1,005.34 | $1,085.45 | $5,192.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.00 / $1,070.36 / $1,249.71
| Professional | | $1,030.00 | $1,070.36 | $1,249.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.38 / $1,361.59 / $2,731.42
| Professional | | $920.38 | $1,361.59 | $2,731.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.89 / $1,455.53 / $2,366.76
| Professional | | $1,117.89 | $1,455.53 | $2,366.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.55 / $1,176.50 / $2,132.25
| Professional | | $775.55 | $1,176.50 | $2,132.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.41 / $1,297.57 / $1,556.90
| Professional | | $789.41 | $1,297.57 | $1,556.90 |