- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.63 / $1,642.16 / $1,664.35
| Professional | | $1,464.63 | $1,642.16 | $1,664.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.77 / $1,775.30 / $2,414.41
| Professional | | $1,597.77 | $1,775.30 | $2,414.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.13 / $2,773.91 / $3,328.70
| Professional | | $2,219.13 | $2,773.91 | $3,328.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,042.99 / $2,019.36
| Professional | | $932.03 | $1,042.99 | $2,019.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.47 / $1,549.20 / $1,936.50
| Professional | | $1,510.47 | $1,549.20 | $1,936.50 |