- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,962.38 / $2,021.45 / $2,021.45
| Professional | | $1,962.38 | $2,021.45 | $2,021.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,573.67 / $2,573.67 / $5,901.94
| Professional | | $2,573.67 | $2,573.67 | $5,901.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,829.65 / $2,871.75 / $3,732.95
| Professional | | $1,829.65 | $2,871.75 | $3,732.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.88 / $2,482.55 / $3,732.95
| Professional | | $1,736.88 | $2,482.55 | $3,732.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,132.83 / $2,344.61 / $6,815.94
| Professional | | $2,132.83 | $2,344.61 | $6,815.94 |