- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.16 / $2,152.69 / $2,939.92
| Professional | | $1,736.16 | $2,152.69 | $2,939.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,994.35 / $2,449.67 / $3,376.41
| Professional | | $1,994.35 | $2,449.67 | $3,376.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.63 / $2,746.01 / $4,238.47
| Professional | | $1,806.63 | $2,746.01 | $4,238.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.33 / $2,420.83 / $3,713.68
| Professional | | $2,092.33 | $2,420.83 | $3,713.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.24 / $2,144.79 / $2,612.67
| Professional | | $1,429.24 | $2,144.79 | $2,612.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,687.79 / $2,657.62 / $3,713.68
| Professional | | $1,687.79 | $2,657.62 | $3,713.68 |