- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,398.83 / $3,981.07
| Professional | | $1,445.44 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,630.27 / $3,981.07
| Professional | | $1,659.59 | $2,630.27 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,511.89 / $3,981.07
| Professional | | $2,290.87 | $2,511.89 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $3,311.31
| Professional | | $2,137.96 | $2,570.40 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,818.38 / $5,888.44
| Professional | | $1,778.28 | $2,818.38 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $3,715.35
| Professional | | $2,089.30 | $3,019.95 | $3,715.35 |