- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,755.07 / $3,356.97 / $14,846.80
| Professional | | $2,755.07 | $3,356.97 | $14,846.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,050.00 / $3,296.88 / $3,775.47
| Professional | | $3,050.00 | $3,296.88 | $3,775.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.08 / $3,720.05 / $7,194.24
| Professional | | $2,464.08 | $3,720.05 | $7,194.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,886.45 / $3,723.52 / $6,318.48
| Professional | | $2,886.45 | $3,723.52 | $6,318.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,402.35 / $3,370.01 / $6,216.61
| Professional | | $2,402.35 | $3,370.01 | $6,216.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,310.08 / $3,319.42 / $4,107.47
| Professional | | $2,310.08 | $3,319.42 | $4,107.47 |