- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.54 / $1,317.50 / $1,317.50
| Professional | | $1,286.54 | $1,317.50 | $1,317.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.30 / $1,695.30 / $3,878.27
| Professional | | $1,695.30 | $1,695.30 | $3,878.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.81 / $1,868.37 / $2,435.87
| Professional | | $1,195.81 | $1,868.37 | $2,435.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.54 / $1,618.51 / $2,435.87
| Professional | | $1,131.54 | $1,618.51 | $2,435.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.73 / $1,529.93 / $2,579.29
| Professional | | $1,256.73 | $1,529.93 | $2,579.29 |