- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $3,019.95
| Professional | | $1,122.02 | $1,479.11 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $3,801.89
| Professional | | $2,290.87 | $3,019.95 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,754.23 / $3,981.07
| Professional | | $1,621.81 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,884.03 / $10,964.78
| Professional | | $1,584.89 | $2,884.03 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,511.89 / $3,388.44
| Professional | | $1,412.54 | $2,511.89 | $3,388.44 |