- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $4,897.79
| Professional | | $1,778.28 | $2,398.83 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,090.30 / $4,570.88
| Professional | | $2,089.30 | $3,090.30 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,884.03 / $4,570.88
| Professional | | $2,041.74 | $2,884.03 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,090.30 / $5,888.44
| Professional | | $2,570.40 | $3,090.30 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $6,456.54
| Professional | | $1,819.70 | $2,691.53 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,570.40 / $4,570.88
| Professional | | $1,778.28 | $2,570.40 | $4,570.88 |