- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,168.69 / $5,888.44
| Professional | | $2,290.87 | $4,168.69 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,897.79 / $7,413.10
| Professional | | $3,019.95 | $4,897.79 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,677.35 / $7,413.10
| Professional | | $4,265.80 | $4,677.35 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,786.30 / $6,165.95
| Professional | | $3,981.07 | $4,786.30 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,570.88 / $5,888.44
| Professional | | $3,388.44 | $4,570.88 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,128.61 / $6,606.93
| Professional | | $3,801.89 | $5,128.61 | $6,606.93 |