- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.83 / $2,033.27 / $10,685.60
| Professional | | $1,761.83 | $2,033.27 | $10,685.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,244.52 / $2,253.66 / $2,575.94
| Professional | | $2,244.52 | $2,253.66 | $2,575.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,919.97 / $2,923.92 / $6,336.61
| Professional | | $1,919.97 | $2,923.92 | $6,336.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,101.35 / $2,794.80 / $4,531.60
| Professional | | $2,101.35 | $2,794.80 | $4,531.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,682.50 / $2,420.01 / $4,149.35
| Professional | | $1,682.50 | $2,420.01 | $4,149.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.34 / $2,416.55 / $2,975.22
| Professional | | $1,623.34 | $2,416.55 | $2,975.22 |