- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,071.87 / $2,071.87 / $2,071.87
| Professional | | $2,071.87 | $2,071.87 | $2,071.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,339.10 / $2,339.10 / $2,339.10
| Professional | | $2,339.10 | $2,339.10 | $2,339.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.76 / $2,837.98 / $2,837.98
| Professional | | $287.76 | $2,837.98 | $2,837.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.94 / $2,071.87 / $2,071.87
| Professional | | $1,454.94 | $2,071.87 | $2,071.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.58 / $1,654.49 / $3,770.66
| Professional | | $1,144.58 | $1,654.49 | $3,770.66 |