- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.60 / $1,409.74 / $2,401.60
| Professional | | $1,113.60 | $1,409.74 | $2,401.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.24 / $1,712.11 / $2,735.51
| Professional | | $1,392.24 | $1,712.11 | $2,735.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.27 / $2,022.01 / $3,229.68
| Professional | | $1,378.27 | $2,022.01 | $3,229.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.54 / $2,494.67 / $11,498.48
| Professional | | $1,652.54 | $2,494.67 | $11,498.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.04 / $1,944.29 / $3,131.11
| Professional | | $1,311.04 | $1,944.29 | $3,131.11 |