- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,162.28 / $5,623.41
| Professional | | $1,698.24 | $3,162.28 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,630.78 / $5,495.41
| Professional | | $2,290.87 | $3,630.78 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $5,495.41
| Professional | | $2,570.40 | $3,467.37 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,630.78 / $4,786.30
| Professional | | $3,019.95 | $3,630.78 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,890.45 / $7,585.78
| Professional | | $2,884.03 | $3,890.45 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,715.35 / $4,786.30
| Professional | | $2,398.83 | $3,715.35 | $4,786.30 |