- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.92 / $2,497.25 / $6,513.01
| Professional | | $1,918.92 | $2,497.25 | $6,513.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.42 / $2,575.48 / $2,950.00
| Professional | | $2,006.42 | $2,575.48 | $2,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,090.92 / $3,054.45 / $6,315.59
| Professional | | $2,090.92 | $3,054.45 | $6,315.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,601.25 / $3,459.66 / $5,451.84
| Professional | | $2,601.25 | $3,459.66 | $5,451.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.40 / $2,881.63 / $5,676.91
| Professional | | $2,012.40 | $2,881.63 | $5,676.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,167.46 / $2,991.44 / $3,584.00
| Professional | | $2,167.46 | $2,991.44 | $3,584.00 |