- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,090.30 / $10,232.93
| Professional | | $1,659.59 | $3,090.30 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $5,128.61
| Professional | | $2,089.30 | $3,388.44 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,235.94 / $5,128.61
| Professional | | $2,818.38 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,311.31 / $4,365.16
| Professional | | $2,754.23 | $3,311.31 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,630.78 / $8,709.64
| Professional | | $2,398.83 | $3,630.78 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,630.78 / $4,570.88
| Professional | | $2,570.40 | $3,630.78 | $4,570.88 |