- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,570.40 / $4,570.88
| Professional | | $1,380.38 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,951.21 / $4,466.84
| Professional | | $1,862.09 | $2,951.21 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,818.38 / $4,466.84
| Professional | | $2,454.71 | $2,818.38 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,801.89
| Professional | | $2,398.83 | $2,884.03 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,162.28 / $6,309.57
| Professional | | $2,041.74 | $3,162.28 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,162.28 / $3,981.07
| Professional | | $2,238.72 | $3,162.28 | $3,981.07 |