- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.80 / $1,495.81 / $1,495.81
| Professional | | $1,482.80 | $1,495.81 | $1,495.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.64 / $2,083.66 / $4,488.42
| Professional | | $1,767.64 | $2,083.66 | $4,488.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.52 / $2,131.86 / $2,806.44
| Professional | | $1,377.52 | $2,131.86 | $2,806.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.76 / $1,864.10 / $2,806.44
| Professional | | $1,301.76 | $1,864.10 | $2,806.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.82 / $1,762.68 / $5,124.25
| Professional | | $1,520.82 | $1,762.68 | $5,124.25 |