- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,505.48 / $1,536.74 / $1,536.74
| Professional | | $1,505.48 | $1,536.74 | $1,536.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.14 / $2,251.62 / $4,543.56
| Professional | | $1,910.14 | $2,251.62 | $4,543.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.86 / $2,197.67 / $2,857.17
| Professional | | $1,399.86 | $2,197.67 | $2,857.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.86 / $1,898.58 / $2,857.17
| Professional | | $1,326.86 | $1,898.58 | $2,857.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.89 / $1,794.55 / $5,216.88
| Professional | | $1,597.89 | $1,794.55 | $5,216.88 |