- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $1,862.09
| Professional | | $1,047.13 | $1,380.38 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,454.71 / $3,715.35
| Professional | | $2,089.30 | $2,454.71 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,951.21
| Professional | | $1,230.27 | $1,737.80 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $3,715.35
| Professional | | $1,698.24 | $1,698.24 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,659.59 / $4,265.80
| Professional | | $1,047.13 | $1,659.59 | $4,265.80 |