- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.27 / $1,258.84 / $1,340.20
| Professional | | $924.27 | $1,258.84 | $1,340.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.23 / $1,652.23 / $3,792.77
| Professional | | $1,652.23 | $1,652.23 | $3,792.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.45 / $1,821.71 / $2,389.25
| Professional | | $1,172.45 | $1,821.71 | $2,389.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.54 / $1,588.04 / $2,389.25
| Professional | | $1,110.54 | $1,588.04 | $2,389.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.70 / $1,500.65 / $4,362.49
| Professional | | $1,346.70 | $1,500.65 | $4,362.49 |