- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.69 / $2,350.00 / $3,587.74
| Professional | | $1,865.69 | $2,350.00 | $3,587.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,745.31 / $3,431.05 / $5,120.45
| Professional | | $2,745.31 | $3,431.05 | $5,120.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,386.50 / $3,560.56 / $5,656.73
| Professional | | $2,386.50 | $3,560.56 | $5,656.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,027.20 / $3,898.79 / $5,980.95
| Professional | | $3,027.20 | $3,898.79 | $5,980.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,145.54 / $2,350.00 / $4,904.13
| Professional | | $2,145.54 | $2,350.00 | $4,904.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,297.50 / $3,246.35 / $5,295.06
| Professional | | $2,297.50 | $3,246.35 | $5,295.06 |