- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.25 / $1,598.24 / $7,766.46
| Professional | | $1,349.25 | $1,598.24 | $7,766.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,066.31 / $2,066.31 / $5,362.80
| Professional | | $2,066.31 | $2,066.31 | $5,362.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.53 / $1,851.70 / $5,362.80
| Professional | | $936.53 | $1,851.70 | $5,362.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.08 / $2,182.23 / $5,362.80
| Professional | | $1,708.08 | $2,182.23 | $5,362.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.33 / $2,080.13 / $6,582.24
| Professional | | $1,823.33 | $2,080.13 | $6,582.24 |