- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.79 / $2,411.77 / $10,590.70
| Professional | | $1,978.79 | $2,411.77 | $10,590.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.00 / $2,622.75 / $2,997.80
| Professional | | $1,950.00 | $2,622.75 | $2,997.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.90 / $2,678.30 / $5,164.80
| Professional | | $1,840.90 | $2,678.30 | $5,164.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.14 / $2,680.80 / $4,519.37
| Professional | | $2,078.14 | $2,680.80 | $4,519.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,726.49 / $2,405.42 / $4,827.05
| Professional | | $1,726.49 | $2,405.42 | $4,827.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.73 / $2,389.86 / $2,957.27
| Professional | | $1,633.73 | $2,389.86 | $2,957.27 |