- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,659.59
| Professional | | $1,584.89 | $1,584.89 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $1,584.89 / $1,584.89
| Professional | | $120.23 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,454.71 / $2,818.38
| Professional | | $2,137.96 | $2,454.71 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $173.78 / $218.78
| Professional | | $144.54 | $173.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $125.89 / $2,511.89
| Professional | | $120.23 | $125.89 | $2,511.89 |