- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,511.89 / $5,623.41
| Professional | | $1,778.28 | $2,511.89 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,090.30 / $4,570.88
| Professional | | $1,862.09 | $3,090.30 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,951.21 / $4,677.35
| Professional | | $2,290.87 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,754.23 / $5,248.07
| Professional | | $2,290.87 | $2,754.23 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $5,623.41
| Professional | | $1,949.84 | $2,884.03 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $4,168.69
| Professional | | $1,819.70 | $2,630.27 | $4,168.69 |