- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.18 / $1,461.51 / $1,461.51
| Professional | | $1,401.18 | $1,461.51 | $1,461.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.58 / $1,950.58 / $4,200.43
| Professional | | $1,950.58 | $1,950.58 | $4,200.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.08 / $2,044.07 / $2,663.37
| Professional | | $1,306.08 | $2,044.07 | $2,663.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.64 / $1,771.92 / $2,663.37
| Professional | | $1,240.64 | $1,771.92 | $2,663.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.05 / $1,672.82 / $4,863.00
| Professional | | $1,583.05 | $1,672.82 | $4,863.00 |