- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.56 / $2,144.13 / $4,815.30
| Professional | | $1,968.56 | $2,144.13 | $4,815.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,078.92 / $2,280.52 / $3,000.00
| Professional | | $2,078.92 | $2,280.52 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,647.06 / $2,141.13 / $4,434.85
| Professional | | $1,647.06 | $2,141.13 | $4,434.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.29 / $2,313.34 / $3,841.66
| Professional | | $1,793.29 | $2,313.34 | $3,841.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.61 / $1,977.10 / $3,344.98
| Professional | | $1,520.61 | $1,977.10 | $3,344.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.30 / $1,417.30 / $2,521.65
| Professional | | $1,417.30 | $1,417.30 | $2,521.65 |