- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,626.65 / $2,908.63 / $3,184.85
| Professional | | $2,626.65 | $2,908.63 | $3,184.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.17 / $2,694.11 / $3,079.37
| Professional | | $1,880.17 | $2,694.11 | $3,079.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.06 / $2,565.69 / $5,999.22
| Professional | | $1,814.06 | $2,565.69 | $5,999.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,376.30 / $3,132.58 / $5,193.16
| Professional | | $2,376.30 | $3,132.58 | $5,193.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.31 / $2,327.06 / $4,238.78
| Professional | | $1,203.31 | $2,327.06 | $4,238.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,872.40 / $1,872.40 / $3,402.48
| Professional | | $1,872.40 | $1,872.40 | $3,402.48 |