- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.40 / $2,275.40 / $2,366.41
| Professional | | $2,275.40 | $2,275.40 | $2,366.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.09 / $2,427.09 / $2,645.53
| Professional | | $2,427.09 | $2,427.09 | $2,645.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,520.99 / $3,520.99 / $3,869.61
| Professional | | $3,520.99 | $3,520.99 | $3,869.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,488.94 / $6,166.93 / $6,166.93
| Professional | | $3,488.94 | $6,166.93 | $6,166.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.22 / $1,820.32 / $2,760.75
| Professional | | $1,274.22 | $1,820.32 | $2,760.75 |