- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.17 / $1,383.94 / $1,497.48
| Professional | | $1,111.17 | $1,383.94 | $1,497.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,579.52 / $2,890.39 / $3,738.51
| Professional | | $2,579.52 | $2,890.39 | $3,738.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,662.00 / $2,916.40 / $4,557.06
| Professional | | $1,662.00 | $2,916.40 | $4,557.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.90 / $2,976.10 / $8,373.92
| Professional | | $1,535.90 | $2,976.10 | $8,373.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.56 / $2,747.13 / $3,367.23
| Professional | | $1,530.56 | $2,747.13 | $3,367.23 |