- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.35 / $1,702.93 / $1,872.48
| Professional | | $1,291.35 | $1,702.93 | $1,872.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.17 / $2,691.36 / $5,116.72
| Professional | | $2,283.17 | $2,691.36 | $5,116.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.22 / $2,495.60 / $3,244.84
| Professional | | $1,581.22 | $2,495.60 | $3,244.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.96 / $2,179.04 / $3,244.84
| Professional | | $1,509.96 | $2,179.04 | $3,244.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.45 / $2,038.04 / $5,924.72
| Professional | | $1,885.45 | $2,038.04 | $5,924.72 |