- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.58 / $1,433.83 / $6,808.46
| Professional | | $1,135.58 | $1,433.83 | $6,808.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.89 / $2,102.71 / $2,921.63
| Professional | | $1,191.89 | $2,102.71 | $2,921.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,362.80 / $3,408.28 / $4,711.52
| Professional | | $2,362.80 | $3,408.28 | $4,711.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,991.65 / $3,378.15 / $9,077.52
| Professional | | $1,991.65 | $3,378.15 | $9,077.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,665.05 / $3,408.28 / $4,132.80
| Professional | | $2,665.05 | $3,408.28 | $4,132.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,863.28 / $2,987.48 / $3,758.09
| Professional | | $1,863.28 | $2,987.48 | $3,758.09 |