- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.82 / $1,085.65 / $1,143.82
| Professional | | $1,055.82 | $1,085.65 | $1,143.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.69 / $2,261.92 / $2,672.48
| Professional | | $2,051.69 | $2,261.92 | $2,672.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.31 / $1,734.62 / $2,519.46
| Professional | | $800.31 | $1,734.62 | $2,519.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.18 / $1,975.62 / $6,966.43
| Professional | | $1,089.18 | $1,975.62 | $6,966.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.72 / $1,866.67 / $2,738.04
| Professional | | $1,034.72 | $1,866.67 | $2,738.04 |