- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.82 / $1,337.21 / $1,337.21
| Professional | | $1,310.82 | $1,337.21 | $1,337.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.92 / $1,966.12 / $3,950.02
| Professional | | $1,667.92 | $1,966.12 | $3,950.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.41 / $1,903.66 / $2,482.83
| Professional | | $1,218.41 | $1,903.66 | $2,482.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.60 / $1,650.12 / $2,482.83
| Professional | | $1,153.60 | $1,650.12 | $2,482.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.54 / $1,559.43 / $4,533.38
| Professional | | $1,378.54 | $1,559.43 | $4,533.38 |