- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.79 / $1,499.29 / $1,749.31
| Professional | | $1,214.79 | $1,499.29 | $1,749.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,782.36 / $3,117.69 / $3,971.74
| Professional | | $2,782.36 | $3,117.69 | $3,971.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.58 / $3,080.53 / $4,095.19
| Professional | | $1,785.58 | $3,080.53 | $4,095.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.18 / $3,152.84 / $9,077.52
| Professional | | $1,671.18 | $3,152.84 | $9,077.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.18 / $2,977.69 / $3,503.16
| Professional | | $1,671.18 | $2,977.69 | $3,503.16 |