- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,086.42 / $3,818.17 / $5,947.45
| Professional | | $3,086.42 | $3,818.17 | $5,947.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,805.11 / $4,191.72 / $4,791.14
| Professional | | $3,805.11 | $4,191.72 | $4,791.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,018.81 / $3,691.73 / $8,138.87
| Professional | | $3,018.81 | $3,691.73 | $8,138.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,289.25 / $4,243.13 / $7,031.50
| Professional | | $3,289.25 | $4,243.13 | $7,031.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,706.75 / $3,754.84 / $7,708.04
| Professional | | $2,706.75 | $3,754.84 | $7,708.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,603.44 / $2,603.44 / $4,624.22
| Professional | | $2,603.44 | $2,603.44 | $4,624.22 |