- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,517.70 / $1,517.70 / $6,734.35
| Professional | | $1,517.70 | $1,517.70 | $6,734.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.73 / $1,744.73 / $4,591.18
| Professional | | $1,744.73 | $1,744.73 | $4,591.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.66 / $2,209.66 / $4,591.18
| Professional | | $1,076.66 | $2,209.66 | $4,591.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.45 / $2,209.66 / $4,591.18
| Professional | | $1,763.45 | $2,209.66 | $4,591.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.18 / $1,816.86 / $5,635.17
| Professional | | $1,557.18 | $1,816.86 | $5,635.17 |