- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.74 / $1,543.58 / $2,458.98
| Professional | | $1,225.74 | $1,543.58 | $2,458.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.16 / $2,103.71 / $2,563.44
| Professional | | $1,788.16 | $2,103.71 | $2,563.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.41 / $2,047.83 / $3,141.59
| Professional | | $1,498.41 | $2,047.83 | $3,141.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.21 / $2,348.94 / $11,498.48
| Professional | | $1,761.21 | $2,348.94 | $11,498.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.83 / $1,863.28 / $2,591.07
| Professional | | $1,513.83 | $1,863.28 | $2,591.07 |