- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,426.57 / $2,598.44 / $12,523.90
| Professional | | $2,426.57 | $2,598.44 | $12,523.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,828.63 / $2,828.63 / $3,350.00
| Professional | | $2,828.63 | $2,828.63 | $3,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,206.76 / $3,255.70 / $6,588.76
| Professional | | $2,206.76 | $3,255.70 | $6,588.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,709.29 / $3,603.36 / $5,680.57
| Professional | | $2,709.29 | $3,603.36 | $5,680.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.20 / $2,943.76 / $5,240.74
| Professional | | $1,993.20 | $2,943.76 | $5,240.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.48 / $3,115.68 / $3,729.69
| Professional | | $2,169.48 | $3,115.68 | $3,729.69 |