- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.79 / $2,711.67 / $2,711.67
| Professional | | $1,091.79 | $2,711.67 | $2,711.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,558.69 / $2,781.20 / $2,802.05
| Professional | | $2,558.69 | $2,781.20 | $2,802.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,096.63 / $2,711.67 / $3,956.48
| Professional | | $2,096.63 | $2,711.67 | $3,956.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.92 / $2,363.14 / $3,677.05
| Professional | | $2,122.92 | $2,363.14 | $3,677.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.79 / $1,255.55 / $2,711.67
| Professional | | $1,091.79 | $1,255.55 | $2,711.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,118.40 / $3,071.68 / $3,972.00
| Professional | | $2,118.40 | $3,071.68 | $3,972.00 |