- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $2,691.53
| Professional | | $1,621.81 | $1,995.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,570.40 / $3,801.89
| Professional | | $1,584.89 | $2,570.40 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,290.87 / $3,890.45
| Professional | | $1,148.15 | $2,290.87 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,344.23 / $4,466.84
| Professional | | $1,949.84 | $2,344.23 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,398.83 / $4,786.30
| Professional | | $1,621.81 | $2,398.83 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,290.87 / $3,467.37
| Professional | | $1,479.11 | $2,290.87 | $3,467.37 |