- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.34 / $1,280.52 / $1,280.52
| Professional | | $1,265.34 | $1,280.52 | $1,280.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,593.88 / $1,878.84 / $3,813.42
| Professional | | $1,593.88 | $1,878.84 | $3,813.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.52 / $1,836.52 / $2,395.75
| Professional | | $1,175.52 | $1,836.52 | $2,395.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.86 / $1,592.30 / $2,395.75
| Professional | | $1,112.86 | $1,592.30 | $2,395.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.83 / $1,504.73 / $4,374.37
| Professional | | $1,331.83 | $1,504.73 | $4,374.37 |