- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.97 / $1,912.30 / $2,721.47
| Professional | | $1,753.97 | $1,912.30 | $2,721.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.00 / $2,051.75 / $2,345.16
| Professional | | $1,733.00 | $2,051.75 | $2,345.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.13 / $1,805.45 / $3,943.46
| Professional | | $1,464.13 | $1,805.45 | $3,943.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,594.79 / $2,057.28 / $3,411.56
| Professional | | $1,594.79 | $2,057.28 | $3,411.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.26 / $1,761.32 / $2,982.27
| Professional | | $1,303.26 | $1,761.32 | $2,982.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.33 / $1,275.33 / $2,242.17
| Professional | | $1,275.33 | $1,275.33 | $2,242.17 |