- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.35 / $1,686.46 / $1,709.25
| Professional | | $1,481.35 | $1,686.46 | $1,709.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.20 / $2,051.10 / $2,338.25
| Professional | | $1,823.20 | $2,051.10 | $2,338.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.52 / $1,194.52 / $1,194.52
| Professional | | $1,194.52 | $1,194.52 | $1,194.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.00 / $2,734.80 / $3,418.50
| Professional | | $2,279.00 | $2,734.80 | $3,418.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.18 / $1,048.33 / $2,073.84
| Professional | | $957.18 | $1,048.33 | $2,073.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.50 / $1,139.50 / $1,139.50
| Professional | | $1,139.50 | $1,139.50 | $1,139.50 |