- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.80 / $1,593.28 / $3,550.98
| Professional | | $1,184.80 | $1,593.28 | $3,550.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.78 / $2,324.42 / $3,594.86
| Professional | | $1,202.78 | $2,324.42 | $3,594.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.68 / $2,706.23 / $3,735.52
| Professional | | $1,755.68 | $2,706.23 | $3,735.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.46 / $2,369.05 / $2,918.27
| Professional | | $1,265.46 | $2,369.05 | $2,918.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.58 / $2,560.21 / $4,263.71
| Professional | | $1,345.58 | $2,560.21 | $4,263.71 |