- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,768.17 / $1,926.76 / $2,184.07
| Professional | | $1,768.17 | $1,926.76 | $2,184.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.21 / $1,674.21 / $2,126.25
| Professional | | $1,674.21 | $1,674.21 | $2,126.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.44 / $2,240.94 / $4,017.92
| Professional | | $1,470.44 | $2,240.94 | $4,017.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.36 / $2,068.33 / $3,424.57
| Professional | | $1,603.36 | $2,068.33 | $3,424.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.69 / $2,069.90 / $3,151.05
| Professional | | $1,476.69 | $2,069.90 | $3,151.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.36 / $1,603.36 / $2,253.23
| Professional | | $1,603.36 | $1,603.36 | $2,253.23 |