- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.83 / $1,300.77 / $1,418.31
| Professional | | $1,115.83 | $1,300.77 | $1,418.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,216.51 / $2,735.38 / $3,304.13
| Professional | | $2,216.51 | $2,735.38 | $3,304.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.74 / $2,805.10 / $3,684.72
| Professional | | $1,549.74 | $2,805.10 | $3,684.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.72 / $2,728.30 / $13,126.00
| Professional | | $1,449.72 | $2,728.30 | $13,126.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.72 / $2,576.71 / $3,189.38
| Professional | | $1,449.72 | $2,576.71 | $3,189.38 |