- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.06 / $2,019.85 / $2,708.32
| Professional | | $1,512.06 | $2,019.85 | $2,708.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,625.00 / $2,625.00 / $2,783.34
| Professional | | $2,625.00 | $2,625.00 | $2,783.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,837.98 / $2,837.98 / $2,837.98
| Professional | | $2,837.98 | $2,837.98 | $2,837.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,053.00 / $3,780.86 / $4,880.18
| Professional | | $3,053.00 | $3,780.86 | $4,880.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.46 / $1,876.24 / $2,828.04
| Professional | | $1,369.46 | $1,876.24 | $2,828.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.63 / $2,011.63 / $2,339.10
| Professional | | $2,011.63 | $2,011.63 | $2,339.10 |