- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.34 / $1,960.34 / $1,960.34
| Professional | | $1,960.34 | $1,960.34 | $1,960.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.60 / $2,261.92 / $2,465.50
| Professional | | $2,010.60 | $2,261.92 | $2,465.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,916.99 / $2,916.99 / $3,205.80
| Professional | | $2,916.99 | $2,916.99 | $3,205.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,890.24 / $10,061.87 / $10,061.87
| Professional | | $2,890.24 | $10,061.87 | $10,061.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.57 / $1,507.95 / $3,996.07
| Professional | | $1,055.57 | $1,507.95 | $3,996.07 |