- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $3,890.45
| Professional | | $1,071.52 | $1,288.25 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,548.82 / $2,511.89
| Professional | | $870.96 | $1,548.82 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,621.81 / $1,949.84
| Professional | | $1,174.90 | $1,621.81 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $2,754.23
| Professional | | $1,288.25 | $1,584.89 | $2,754.23 |