- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.97 / $1,615.17 / $1,710.95
| Professional | | $1,179.97 | $1,615.17 | $1,710.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,010.26 / $2,010.26 / $4,869.89
| Professional | | $2,010.26 | $2,010.26 | $4,869.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,503.15 / $2,335.52 / $3,067.81
| Professional | | $1,503.15 | $2,335.52 | $3,067.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.51 / $2,039.17 / $3,067.81
| Professional | | $1,425.51 | $2,039.17 | $3,067.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.87 / $1,926.85 / $5,601.48
| Professional | | $1,698.87 | $1,926.85 | $5,601.48 |