- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,197.21 / $1,288.58 / $6,456.87
| Professional | | $1,197.21 | $1,288.58 | $6,456.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,474.83 / $1,474.83 / $4,352.72
| Professional | | $1,474.83 | $1,474.83 | $4,352.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.91 / $2,024.93 / $4,352.72
| Professional | | $1,067.91 | $2,024.93 | $4,352.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.81 / $2,016.77 / $4,352.72
| Professional | | $1,326.81 | $2,016.77 | $4,352.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.39 / $1,742.33 / $5,342.49
| Professional | | $1,372.39 | $1,742.33 | $5,342.49 |