- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.60 / $1,346.94 / $1,346.94
| Professional | | $1,123.60 | $1,346.94 | $1,346.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.76 / $2,022.49 / $3,975.61
| Professional | | $1,715.76 | $2,022.49 | $3,975.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.69 / $1,916.51 / $2,500.03
| Professional | | $1,226.69 | $1,916.51 | $2,500.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.70 / $1,661.85 / $2,500.03
| Professional | | $1,161.70 | $1,661.85 | $2,500.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.95 / $1,570.23 / $4,564.76
| Professional | | $1,400.95 | $1,570.23 | $4,564.76 |