- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $2,344.23
| Professional | | $1,412.54 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $6,456.54
| Professional | | $2,089.30 | $2,089.30 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,630.78
| Professional | | $3,090.30 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Professional | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,511.89 / $2,511.89
| Professional | | $1,778.28 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,513.56
| Professional | | $1,047.13 | $1,047.13 | $1,513.56 |