- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.90 / $1,239.08 / $1,239.08
| Professional | | $1,176.90 | $1,239.08 | $1,239.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.50 / $2,222.60 / $3,550.83
| Professional | | $1,885.50 | $2,222.60 | $3,550.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.07 / $1,705.98 / $2,227.98
| Professional | | $1,093.07 | $1,705.98 | $2,227.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.55 / $1,513.77 / $2,227.98
| Professional | | $1,034.55 | $1,513.77 | $2,227.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.48 / $1,523.83 / $2,370.34
| Professional | | $1,149.48 | $1,523.83 | $2,370.34 |