- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.33 / $1,257.74 / $1,257.74
| Professional | | $1,220.33 | $1,257.74 | $1,257.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,585.55 / $1,869.01 / $3,691.29
| Professional | | $1,585.55 | $1,869.01 | $3,691.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.40 / $1,774.74 / $2,318.91
| Professional | | $1,128.40 | $1,774.74 | $2,318.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.86 / $1,537.11 / $2,318.91
| Professional | | $1,075.86 | $1,537.11 | $2,318.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.76 / $1,456.48 / $4,234.08
| Professional | | $1,295.76 | $1,456.48 | $4,234.08 |