- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,517.44 / $2,866.02 / $2,904.75
| Professional | | $2,517.44 | $2,866.02 | $2,904.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,098.40 / $3,098.40 / $3,532.18
| Professional | | $3,098.40 | $3,098.40 | $3,532.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.17 / $2,875.69 / $19,896.06
| Professional | | $2,122.17 | $2,875.69 | $19,896.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,873.00 / $4,647.60 / $5,809.50
| Professional | | $3,873.00 | $4,647.60 | $5,809.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.66 / $1,742.85 / $3,524.35
| Professional | | $1,626.66 | $1,742.85 | $3,524.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,936.50 / $3,079.03 / $3,079.03
| Professional | | $1,936.50 | $3,079.03 | $3,079.03 |