- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,136.23 / $2,184.29 / $2,184.29
| Professional | | $2,136.23 | $2,184.29 | $2,184.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,719.52 / $3,205.72 / $6,338.67
| Professional | | $2,719.52 | $3,205.72 | $6,338.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,072.88 / $3,134.46 / $4,038.15
| Professional | | $2,072.88 | $3,134.46 | $4,038.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,889.09 / $2,718.97 / $4,038.15
| Professional | | $1,889.09 | $2,718.97 | $4,038.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.67 / $2,536.30 / $7,373.19
| Professional | | $2,243.67 | $2,536.30 | $7,373.19 |