- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.67 / $2,440.98 / $2,440.98
| Professional | | $1,838.67 | $2,440.98 | $2,440.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.65 / $717.65 / $1,125.72
| Professional | | $717.65 | $717.65 | $1,125.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.92 / $1,818.00 / $2,495.31
| Professional | | $891.92 | $1,818.00 | $2,495.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.55 / $1,312.55 / $1,312.55
| Professional | | $1,312.55 | $1,312.55 | $1,312.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.33 / $1,019.16 / $1,559.47
| Professional | | $738.33 | $1,019.16 | $1,559.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.26 / $1,386.09 / $2,326.98
| Professional | | $1,114.26 | $1,386.09 | $2,326.98 |