- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.81 / $1,860.18 / $2,175.67
| Professional | | $1,334.81 | $1,860.18 | $2,175.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,676.24 / $5,676.24 / $5,676.24
| Professional | | $5,676.24 | $5,676.24 | $5,676.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.84 / $2,601.67 / $3,774.80
| Professional | | $1,650.84 | $2,601.67 | $3,774.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.67 / $2,625.93 / $3,774.80
| Professional | | $1,790.67 | $2,625.93 | $3,774.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.76 / $2,370.90 / $6,892.38
| Professional | | $2,217.76 | $2,370.90 | $6,892.38 |