- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $3,311.31
| Professional | | $1,479.11 | $1,737.80 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $5,754.40
| Professional | | $2,041.74 | $2,041.74 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,630.27 / $6,456.54
| Professional | | $1,412.54 | $2,630.27 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $4,073.80
| Professional | | $1,698.24 | $2,238.72 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $3,890.45
| Professional | | $1,698.24 | $2,238.72 | $3,890.45 |