- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.05 / $1,333.96 / $2,128.16
| Professional | | $1,080.05 | $1,333.96 | $2,128.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.03 / $1,942.05 / $4,179.26
| Professional | | $1,168.03 | $1,942.05 | $4,179.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.44 / $2,067.30 / $2,155.62
| Professional | | $1,559.44 | $2,067.30 | $2,155.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.87 / $1,612.24 / $3,255.36
| Professional | | $998.87 | $1,612.24 | $3,255.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.94 / $1,787.49 / $4,249.75
| Professional | | $1,109.94 | $1,787.49 | $4,249.75 |