- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.72 / $3,413.04 / $5,788.61
| Professional | | $1,094.72 | $3,413.04 | $5,788.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,020.88 / $4,056.22 / $4,934.08
| Professional | | $3,020.88 | $4,056.22 | $4,934.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,810.10 / $3,372.12 / $6,845.75
| Professional | | $2,810.10 | $3,372.12 | $6,845.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,332.50 / $5,966.68 / $7,000.00
| Professional | | $4,332.50 | $5,966.68 | $7,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,765.49 / $5,666.10 / $7,552.60
| Professional | | $1,765.49 | $5,666.10 | $7,552.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,212.70 / $4,895.39 / $7,138.96
| Professional | | $3,212.70 | $4,895.39 | $7,138.96 |