- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.30 / $1,101.30 / $5,564.50
| Professional | | $1,101.30 | $1,101.30 | $5,564.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.97 / $1,359.97 / $3,962.78
| Professional | | $1,359.97 | $1,359.97 | $3,962.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.69 / $1,515.11 / $3,962.78
| Professional | | $857.69 | $1,515.11 | $3,962.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.83 / $1,618.12 / $3,962.78
| Professional | | $1,079.83 | $1,618.12 | $3,962.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.05 / $1,479.81 / $4,863.87
| Professional | | $1,151.05 | $1,479.81 | $4,863.87 |