- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.14 / $1,873.65 / $4,043.84
| Professional | | $1,360.14 | $1,873.65 | $4,043.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.91 / $1,989.16 / $2,800.00
| Professional | | $1,830.91 | $1,989.16 | $2,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.04 / $1,876.40 / $3,873.22
| Professional | | $1,416.04 | $1,876.40 | $3,873.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.92 / $2,034.23 / $3,367.58
| Professional | | $1,576.92 | $2,034.23 | $3,367.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.91 / $1,802.13 / $3,599.71
| Professional | | $1,320.91 | $1,802.13 | $3,599.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.94 / $1,235.94 / $2,212.42
| Professional | | $1,235.94 | $1,235.94 | $2,212.42 |