- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.64 / $1,113.64 / $1,165.92
| Professional | | $1,113.64 | $1,113.64 | $1,165.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.53 / $1,874.89 / $3,535.95
| Professional | | $1,590.53 | $1,874.89 | $3,535.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.48 / $1,581.58 / $2,205.85
| Professional | | $1,074.48 | $1,581.58 | $2,205.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.58 / $1,463.16 / $2,205.85
| Professional | | $1,019.58 | $1,463.16 | $2,205.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.90 / $1,385.47 / $4,027.65
| Professional | | $1,153.90 | $1,385.47 | $4,027.65 |