- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $6,760.83
| Professional | | $2,238.72 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,801.89 / $5,495.41
| Professional | | $2,187.76 | $3,801.89 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,801.89 / $5,754.40
| Professional | | $2,884.03 | $3,801.89 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $6,165.95
| Professional | | $2,754.23 | $3,388.44 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,630.78 / $7,762.47
| Professional | | $2,570.40 | $3,630.78 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,311.31 / $5,128.61
| Professional | | $2,238.72 | $3,311.31 | $5,128.61 |