- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.50 / $1,423.70 / $1,805.47
| Professional | | $1,148.50 | $1,423.70 | $1,805.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.08 / $1,826.02 / $4,087.11
| Professional | | $1,549.08 | $1,826.02 | $4,087.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.75 / $1,904.57 / $3,202.66
| Professional | | $1,214.75 | $1,904.57 | $3,202.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.33 / $1,825.00 / $3,202.66
| Professional | | $1,190.33 | $1,825.00 | $3,202.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.29 / $1,656.94 / $4,720.76
| Professional | | $1,115.29 | $1,656.94 | $4,720.76 |