- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.21 / $1,137.42 / $5,783.87
| Professional | | $1,079.21 | $1,137.42 | $5,783.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.40 / $1,717.40 / $3,847.51
| Professional | | $1,717.40 | $1,717.40 | $3,847.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.13 / $1,610.41 / $3,847.51
| Professional | | $855.13 | $1,610.41 | $3,847.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.01 / $1,610.41 / $3,847.51
| Professional | | $1,143.01 | $1,610.41 | $3,847.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.51 / $1,551.58 / $4,722.39
| Professional | | $1,274.51 | $1,551.58 | $4,722.39 |