- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,311.31 / $5,754.40
| Professional | | $1,778.28 | $3,311.31 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,801.89 / $5,888.44
| Professional | | $2,398.83 | $3,801.89 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,630.78 / $5,754.40
| Professional | | $2,290.87 | $3,630.78 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,801.89 / $4,897.79
| Professional | | $3,162.28 | $3,801.89 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,630.78 / $6,918.31
| Professional | | $2,089.30 | $3,630.78 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,890.45 / $5,011.87
| Professional | | $2,290.87 | $3,890.45 | $5,011.87 |