- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.77 / $2,266.77 / $2,472.46
| Professional | | $2,266.77 | $2,266.77 | $2,472.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,647.43 / $3,120.74 / $7,543.72
| Professional | | $2,647.43 | $3,120.74 | $7,543.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,504.23 / $2,808.15 / $4,744.81
| Professional | | $2,504.23 | $2,808.15 | $4,744.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,232.07 / $2,958.59 / $4,744.81
| Professional | | $2,232.07 | $2,958.59 | $4,744.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,439.98 / $2,980.14 / $8,663.46
| Professional | | $2,439.98 | $2,980.14 | $8,663.46 |