- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.13 / $2,273.48 / $3,955.86
| Professional | | $1,943.13 | $2,273.48 | $3,955.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,472.10 / $2,472.10 / $2,825.61
| Professional | | $2,472.10 | $2,472.10 | $2,825.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.49 / $2,916.02 / $5,760.86
| Professional | | $2,043.49 | $2,916.02 | $5,760.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,369.81 / $3,110.10 / $4,969.77
| Professional | | $2,369.81 | $3,110.10 | $4,969.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.95 / $2,743.88 / $5,332.65
| Professional | | $1,873.95 | $2,743.88 | $5,332.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.76 / $2,725.28 / $3,263.75
| Professional | | $2,014.76 | $2,725.28 | $3,263.75 |