- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.23 / $2,053.63 / $9,858.31
| Professional | | $1,851.23 | $2,053.63 | $9,858.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,540.81 / $2,540.81 / $6,601.07
| Professional | | $2,540.81 | $2,540.81 | $6,601.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.07 / $3,138.65 / $6,601.07
| Professional | | $1,451.07 | $3,138.65 | $6,601.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.77 / $3,129.80 / $6,601.07
| Professional | | $2,014.77 | $3,129.80 | $6,601.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,308.57 / $2,657.07 / $8,102.07
| Professional | | $2,308.57 | $2,657.07 | $8,102.07 |