- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,701.85 / $2,941.85 / $6,410.76
| Professional | | $2,701.85 | $2,941.85 | $6,410.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,775.00 / $3,154.84 / $3,605.97
| Professional | | $2,775.00 | $3,154.84 | $3,605.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.01 / $2,704.29 / $6,056.99
| Professional | | $2,084.01 | $2,704.29 | $6,056.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,448.64 / $3,158.75 / $5,234.41
| Professional | | $2,448.64 | $3,158.75 | $5,234.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.08 / $2,590.44 / $5,283.34
| Professional | | $1,865.08 | $2,590.44 | $5,283.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.88 / $1,961.88 / $3,442.44
| Professional | | $1,961.88 | $1,961.88 | $3,442.44 |