- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,166.92 / $2,516.17 / $3,189.19
| Professional | | $2,166.92 | $2,516.17 | $3,189.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.84 / $389.84 / $1,814.35
| Professional | | $389.84 | $389.84 | $1,814.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.45 / $1,461.61 / $2,718.72
| Professional | | $957.45 | $1,461.61 | $2,718.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.50 / $2,166.71 / $3,046.40
| Professional | | $1,417.50 | $2,166.71 | $3,046.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.00 / $1,968.75 / $2,971.65
| Professional | | $533.00 | $1,968.75 | $2,971.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.28 / $1,451.48 / $4,395.31
| Professional | | $655.28 | $1,451.48 | $4,395.31 |