- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,693.72 / $1,693.72 / $1,693.72
| Professional | | $1,693.72 | $1,693.72 | $1,693.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.28 / $2,094.25 / $2,474.37
| Professional | | $1,888.28 | $2,094.25 | $2,474.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.92 / $1,896.15 / $2,609.77
| Professional | | $1,516.92 | $1,896.15 | $2,609.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.41 / $2,598.52 / $8,883.41
| Professional | | $1,311.41 | $2,598.52 | $8,883.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.35 / $2,012.09 / $3,097.36
| Professional | | $1,192.35 | $2,012.09 | $3,097.36 |