- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $6,918.31
| Professional | | $2,187.76 | $3,019.95 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,311.31 / $5,011.87
| Professional | | $2,041.74 | $3,311.31 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,162.28 / $5,011.87
| Professional | | $2,754.23 | $3,162.28 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,235.94 / $4,265.80
| Professional | | $2,691.53 | $3,235.94 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,467.37 / $8,912.51
| Professional | | $2,187.76 | $3,467.37 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,467.37 / $4,466.84
| Professional | | $2,454.71 | $3,467.37 | $4,466.84 |