- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,548.13 / $4,168.69
| Professional | | $2,570.40 | $3,548.13 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,168.69 / $7,585.78
| Professional | | $3,548.13 | $4,168.69 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,265.80 / $6,456.54
| Professional | | $3,090.30 | $4,265.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,548.13 / $4,570.88
| Professional | | $2,951.21 | $3,548.13 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,801.89 / $4,365.16
| Professional | | $2,570.40 | $3,801.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,311.31 / $4,570.88
| Professional | | $2,454.71 | $3,311.31 | $4,570.88 |