- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,344.23 / $5,495.41
| Professional | | $1,862.09 | $2,344.23 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $4,365.16
| Professional | | $1,819.70 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,090.30 / $4,786.30
| Professional | | $2,290.87 | $3,090.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $5,128.61
| Professional | | $2,290.87 | $2,818.38 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $6,456.54
| Professional | | $2,041.74 | $2,818.38 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,691.53 / $4,466.84
| Professional | | $1,949.84 | $2,691.53 | $4,466.84 |