- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,630.27 / $5,495.41
| Professional | | $1,778.28 | $2,630.27 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,467.37 / $4,677.35
| Professional | | $2,238.72 | $3,467.37 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,090.30 / $5,011.87
| Professional | | $2,137.96 | $3,090.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,388.44 / $6,309.57
| Professional | | $2,818.38 | $3,388.44 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,090.30 / $6,918.31
| Professional | | $1,995.26 | $3,090.30 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,754.23 / $5,011.87
| Professional | | $1,949.84 | $2,754.23 | $5,011.87 |