- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.32 / $1,045.90 / $1,379.72
| Professional | | $1,001.32 | $1,045.90 | $1,379.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.22 / $1,126.22 / $1,126.22
| Professional | | $1,126.22 | $1,126.22 | $1,126.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.24 / $1,047.46 / $1,763.71
| Professional | | $397.24 | $1,047.46 | $1,763.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.82 / $1,253.64 / $6,966.43
| Professional | | $366.82 | $1,253.64 | $6,966.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.55 / $1,118.63 / $2,028.92
| Professional | | $345.55 | $1,118.63 | $2,028.92 |