- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.65 / $1,163.45 / $1,844.21
| Professional | | $1,069.65 | $1,163.45 | $1,844.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.05 / $1,749.47 / $1,749.47
| Professional | | $1,487.05 | $1,749.47 | $1,749.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,231.19 / $1,598.61 / $2,445.14
| Professional | | $1,231.19 | $1,598.61 | $2,445.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.95 / $1,538.34 / $9,976.00
| Professional | | $1,251.95 | $1,538.34 | $9,976.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.95 / $1,469.57 / $2,013.97
| Professional | | $1,251.95 | $1,469.57 | $2,013.97 |