- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.55 / $1,661.55 / $1,728.01
| Professional | | $1,661.55 | $1,661.55 | $1,728.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,772.32 / $1,993.86 / $2,173.31
| Professional | | $1,772.32 | $1,993.86 | $2,173.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,571.19 / $2,571.19 / $2,825.76
| Professional | | $2,571.19 | $2,571.19 | $2,825.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,547.71 / $4,503.24 / $4,503.24
| Professional | | $2,547.71 | $4,503.24 | $4,503.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $1,329.24 / $2,015.97
| Professional | | $930.47 | $1,329.24 | $2,015.97 |