- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,504.63 / $2,019.39 / $2,019.39
| Professional | | $1,504.63 | $2,019.39 | $2,019.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.64 / $1,739.72 / $2,559.21
| Professional | | $1,412.64 | $1,739.72 | $2,559.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.72 / $2,019.39 / $2,863.14
| Professional | | $1,583.72 | $2,019.39 | $2,863.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.94 / $1,660.75 / $2,584.13
| Professional | | $1,491.94 | $1,660.75 | $2,584.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.82 / $1,504.63 / $2,019.39
| Professional | | $1,416.82 | $1,504.63 | $2,019.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.32 / $1,922.11 / $2,605.69
| Professional | | $1,315.32 | $1,922.11 | $2,605.69 |