- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,184.28
| Professional | | $1,172.56 | $1,172.56 | $1,184.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.54 / $1,172.56 / $1,172.56
| Professional | | $380.54 | $1,172.56 | $1,172.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.35 / $1,573.97 / $1,810.07
| Professional | | $1,369.35 | $1,573.97 | $1,810.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.81 / $1,407.07 / $1,641.58
| Professional | | $1,289.81 | $1,407.07 | $1,641.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.55 / $1,172.56 / $1,758.84
| Professional | | $269.55 | $1,172.56 | $1,758.84 |