- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.88 / $1,935.43 / $4,368.68
| Professional | | $1,416.88 | $1,935.43 | $4,368.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,889.65 / $2,055.05 / $2,750.00
| Professional | | $1,889.65 | $2,055.05 | $2,750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,490.14 / $1,928.16 / $3,999.24
| Professional | | $1,490.14 | $1,928.16 | $3,999.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.50 / $2,100.77 / $3,477.64
| Professional | | $1,628.50 | $2,100.77 | $3,477.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.42 / $1,776.39 / $3,007.78
| Professional | | $1,337.42 | $1,776.39 | $3,007.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.11 / $1,277.11 / $2,284.69
| Professional | | $1,277.11 | $1,277.11 | $2,284.69 |