- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.24 / $1,149.24 / $1,234.52
| Professional | | $1,149.24 | $1,149.24 | $1,234.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.51 / $1,789.99 / $3,689.60
| Professional | | $1,518.51 | $1,789.99 | $3,689.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.33 / $1,640.06 / $2,206.94
| Professional | | $1,093.33 | $1,640.06 | $2,206.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.02 / $1,457.91 / $2,206.94
| Professional | | $1,014.02 | $1,457.91 | $2,206.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.55 / $1,386.14 / $4,029.61
| Professional | | $1,196.55 | $1,386.14 | $4,029.61 |