- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.61 / $1,633.61 / $1,633.61
| Professional | | $1,633.61 | $1,633.61 | $1,633.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.60 / $2,261.92 / $2,736.94
| Professional | | $2,010.60 | $2,261.92 | $2,736.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.02 / $1,332.02 / $1,332.02
| Professional | | $1,332.02 | $1,332.02 | $1,332.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,513.25 / $2,890.24 / $3,769.88
| Professional | | $2,513.25 | $2,890.24 | $3,769.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,256.63 / $2,196.98
| Professional | | $1,055.57 | $1,256.63 | $2,196.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.63 / $1,256.63 / $1,256.63
| Professional | | $1,256.63 | $1,256.63 | $1,256.63 |