- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.03 / $1,147.85 / $5,719.28
| Professional | | $1,060.03 | $1,147.85 | $5,719.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,343.97 / $1,343.97 / $3,874.13
| Professional | | $1,343.97 | $1,343.97 | $3,874.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.13 / $1,801.48 / $3,874.13
| Professional | | $935.13 | $1,801.48 | $3,874.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.73 / $1,781.53 / $3,874.13
| Professional | | $1,180.73 | $1,781.53 | $3,874.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.61 / $1,543.46 / $4,755.06
| Professional | | $1,250.61 | $1,543.46 | $4,755.06 |