- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,057.84 / $2,057.84 / $2,460.63
| Professional | | $2,057.84 | $2,057.84 | $2,460.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,378.51 / $2,810.24 / $4,059.30
| Professional | | $2,378.51 | $2,810.24 | $4,059.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,614.67 / $3,029.08 / $4,635.39
| Professional | | $2,614.67 | $3,029.08 | $4,635.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,358.44 / $3,037.47 / $4,659.64
| Professional | | $2,358.44 | $3,037.47 | $4,659.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,057.84 / $2,057.84 / $2,460.63
| Professional | | $2,057.84 | $2,057.84 | $2,460.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,713.53 / $3,339.73 / $4,246.89
| Professional | | $2,713.53 | $3,339.73 | $4,246.89 |