- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.94 / $5,636.70 / $5,636.70
| Professional | | $1,194.94 | $5,636.70 | $5,636.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.06 / $897.06 / $897.06
| Professional | | $897.06 | $897.06 | $897.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.37 / $1,348.34 / $1,955.09
| Professional | | $949.37 | $1,348.34 | $1,955.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.26 / $2,070.63 / $3,866.83
| Professional | | $1,087.26 | $2,070.63 | $3,866.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.34 / $1,666.54 / $5,832.13
| Professional | | $1,538.34 | $1,666.54 | $5,832.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.48 / $1,266.91 / $1,870.29
| Professional | | $987.48 | $1,266.91 | $1,870.29 |