- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.88 / $1,027.88 / $4,338.47
| Professional | | $1,027.88 | $1,027.88 | $4,338.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.69 / $1,080.69 / $1,273.89
| Professional | | $1,080.69 | $1,080.69 | $1,273.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.17 / $1,006.82 / $2,975.07
| Professional | | $848.17 | $1,006.82 | $2,975.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.17 / $956.35 / $2,975.07
| Professional | | $848.17 | $956.35 | $2,975.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.67 / $1,170.88 / $3,651.57
| Professional | | $976.67 | $1,170.88 | $3,651.57 |