- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.27 / $1,240.27 / $1,287.50
| Professional | | $1,240.27 | $1,240.27 | $1,287.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,005.86 / $4,005.86 / $4,005.86
| Professional | | $4,005.86 | $4,005.86 | $4,005.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.35 / $1,557.20 / $2,523.91
| Professional | | $1,291.35 | $1,557.20 | $2,523.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.52 / $1,598.45 / $2,523.91
| Professional | | $1,178.52 | $1,598.45 | $2,523.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.11 / $1,585.22 / $4,608.35
| Professional | | $1,299.11 | $1,585.22 | $4,608.35 |