- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.17 / $2,243.17 / $2,443.11
| Professional | | $2,243.17 | $2,243.17 | $2,443.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,686.18 / $3,166.41 / $7,453.93
| Professional | | $2,686.18 | $3,166.41 | $7,453.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,577.69 / $2,889.80 / $4,688.12
| Professional | | $2,577.69 | $2,889.80 | $4,688.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.21 / $2,922.49 / $4,688.12
| Professional | | $2,205.21 | $2,922.49 | $4,688.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,431.80 / $2,944.54 / $8,559.98
| Professional | | $2,431.80 | $2,944.54 | $8,559.98 |