- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.99 / $1,990.30 / $2,059.96
| Professional | | $1,656.99 | $1,990.30 | $2,059.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,433.21 / $2,868.23 / $5,827.62
| Professional | | $2,433.21 | $2,868.23 | $5,827.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.48 / $2,835.83 / $3,684.71
| Professional | | $1,805.48 | $2,835.83 | $3,684.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.19 / $2,449.94 / $3,684.71
| Professional | | $1,714.19 | $2,449.94 | $3,684.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.03 / $2,314.31 / $6,727.87
| Professional | | $2,035.03 | $2,314.31 | $6,727.87 |