- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,630.78 / $5,495.41
| Professional | | $2,089.30 | $3,630.78 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,466.84 / $6,918.31
| Professional | | $2,818.38 | $4,466.84 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,265.80 / $6,760.83
| Professional | | $3,981.07 | $4,265.80 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,365.16 / $5,754.40
| Professional | | $3,715.35 | $4,365.16 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,365.16 / $5,495.41
| Professional | | $3,467.37 | $4,365.16 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,570.88 / $5,888.44
| Professional | | $3,467.37 | $4,570.88 | $5,888.44 |