- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.25 / $3,830.09 / $5,360.72
| Professional | | $2,225.25 | $3,830.09 | $5,360.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,700.00 / $4,145.56 / $4,738.38
| Professional | | $3,700.00 | $4,145.56 | $4,738.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,766.39 / $3,645.77 / $7,936.16
| Professional | | $2,766.39 | $3,645.77 | $7,936.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,208.64 / $4,139.14 / $6,854.26
| Professional | | $3,208.64 | $4,139.14 | $6,854.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,292.25 / $3,287.25 / $6,042.44
| Professional | | $2,292.25 | $3,287.25 | $6,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.27 / $2,563.27 / $4,510.41
| Professional | | $2,563.27 | $2,563.27 | $4,510.41 |