- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,288.25
| Professional | | $1,230.27 | $1,230.27 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,230.27 / $1,380.38
| Professional | | $1,174.90 | $1,230.27 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,412.54 / $1,659.59
| Professional | | $1,230.27 | $1,412.54 | $1,659.59 |
- 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
- $125.89 / $912.01 / $1,412.54
| Professional | | $125.89 | $912.01 | $1,412.54 |