- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.49 / $1,166.49 / $1,205.36
| Professional | | $1,166.49 | $1,166.49 | $1,205.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.65 / $1,965.78 / $3,649.82
| Professional | | $1,667.65 | $1,965.78 | $3,649.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.23 / $1,671.50 / $2,213.02
| Professional | | $1,087.23 | $1,671.50 | $2,213.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.34 / $1,464.01 / $2,213.02
| Professional | | $1,016.34 | $1,464.01 | $2,213.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.02 / $1,389.96 / $4,040.72
| Professional | | $1,223.02 | $1,389.96 | $4,040.72 |