- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,380.86 / $2,604.55 / $5,496.59
| Professional | | $2,380.86 | $2,604.55 | $5,496.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,512.75 / $2,787.61 / $3,700.00
| Professional | | $2,512.75 | $2,787.61 | $3,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.05 / $2,664.50 / $5,337.66
| Professional | | $1,984.05 | $2,664.50 | $5,337.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.05 / $2,800.65 / $4,643.34
| Professional | | $2,171.05 | $2,800.65 | $4,643.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.51 / $2,408.59 / $4,328.78
| Professional | | $1,845.51 | $2,408.59 | $4,328.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.67 / $1,821.67 / $3,044.64
| Professional | | $1,821.67 | $1,821.67 | $3,044.64 |