- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,454.71 / $2,818.38
| Professional | | $1,819.70 | $2,454.71 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,981.07
| Professional | | $1,288.25 | $1,288.25 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,466.84
| Professional | | $3,715.35 | $3,715.35 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Professional | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $3,019.95
| Professional | | $2,137.96 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,819.70
| Professional | | $1,288.25 | $1,288.25 | $1,819.70 |