- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,195.96 / $2,662.42 / $5,625.94
| Professional | | $2,195.96 | $2,662.42 | $5,625.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,579.75 / $2,874.15 / $3,725.00
| Professional | | $2,579.75 | $2,874.15 | $3,725.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,037.33 / $2,653.15 / $5,485.36
| Professional | | $2,037.33 | $2,653.15 | $5,485.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.46 / $2,877.31 / $4,767.14
| Professional | | $2,230.46 | $2,877.31 | $4,767.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.09 / $2,485.36 / $5,059.72
| Professional | | $1,868.09 | $2,485.36 | $5,059.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.21 / $1,878.21 / $3,127.29
| Professional | | $1,878.21 | $1,878.21 | $3,127.29 |