- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.98 / $991.74 / $991.74
| Professional | | $814.98 | $991.74 | $991.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.53 / $1,465.03 / $2,124.29
| Professional | | $1,031.53 | $1,465.03 | $2,124.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.82 / $2,249.08 / $3,307.62
| Professional | | $1,357.82 | $2,249.08 | $3,307.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.35 / $2,121.28 / $3,889.97
| Professional | | $1,181.35 | $2,121.28 | $3,889.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.82 / $1,358.09 / $3,589.10
| Professional | | $541.82 | $1,358.09 | $3,589.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.35 / $956.29 / $1,217.08
| Professional | | $869.35 | $956.29 | $1,217.08 |