- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,162.28 / $3,630.78
| Professional | | $1,778.28 | $3,162.28 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $5,370.32
| Professional | | $3,548.13 | $3,548.13 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,630.78
| Professional | | $3,467.37 | $3,467.37 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,786.30 / $5,623.41
| Professional | | $3,981.07 | $4,786.30 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $6,309.57
| Professional | | $4,168.69 | $4,168.69 | $6,309.57 |