- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,263.04 / $2,653.30 / $2,696.42
| Professional | | $2,263.04 | $2,653.30 | $2,696.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,743.70 / $2,743.70 / $3,484.50
| Professional | | $2,743.70 | $2,743.70 | $3,484.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.91 / $2,676.37 / $5,128.50
| Professional | | $2,101.91 | $2,676.37 | $5,128.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.59 / $2,798.77 / $4,504.96
| Professional | | $2,169.59 | $2,798.77 | $4,504.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.50 / $2,308.98 / $4,417.14
| Professional | | $1,378.50 | $2,308.98 | $4,417.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.21 / $1,876.21 / $1,876.21
| Professional | | $1,876.21 | $1,876.21 | $1,876.21 |