- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,818.38 / $5,011.87
| Professional | | $1,513.56 | $2,818.38 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,235.94 / $4,897.79
| Professional | | $2,041.74 | $3,235.94 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,090.30 / $4,897.79
| Professional | | $2,454.71 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $4,168.69
| Professional | | $2,630.27 | $3,162.28 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,467.37 / $6,760.83
| Professional | | $2,344.23 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,311.31 / $4,265.80
| Professional | | $2,187.76 | $3,311.31 | $4,265.80 |