- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $2,137.96
| Professional | | $1,071.52 | $1,513.56 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $4,073.80
| Professional | | $1,348.96 | $1,584.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,862.09 / $2,691.53
| Professional | | $1,071.52 | $1,862.09 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $4,073.80
| Professional | | $1,862.09 | $1,862.09 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,584.89 / $4,677.35
| Professional | | $1,148.15 | $1,584.89 | $4,677.35 |