- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.75 / $1,451.75 / $6,383.12
| Professional | | $1,451.75 | $1,451.75 | $6,383.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,711.18 / $1,711.18 / $4,351.05
| Professional | | $1,711.18 | $1,711.18 | $4,351.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.96 / $2,088.06 / $4,351.05
| Professional | | $1,033.96 | $2,088.06 | $4,351.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.63 / $2,088.06 / $4,351.05
| Professional | | $1,663.63 | $2,088.06 | $4,351.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.10 / $1,722.38 / $5,340.42
| Professional | | $1,493.10 | $1,722.38 | $5,340.42 |