- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.39 / $2,280.56 / $3,936.84
| Professional | | $1,993.39 | $2,280.56 | $3,936.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,451.04 / $2,801.54
| Professional | | $2,100.00 | $2,451.04 | $2,801.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.98 / $2,303.84 / $4,732.82
| Professional | | $1,756.98 | $2,303.84 | $4,732.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,913.58 / $2,468.52 / $4,094.98
| Professional | | $1,913.58 | $2,468.52 | $4,094.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.50 / $2,115.07 / $4,098.62
| Professional | | $1,578.50 | $2,115.07 | $4,098.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,514.91 / $1,514.91 / $2,690.49
| Professional | | $1,514.91 | $1,514.91 | $2,690.49 |