- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,874.95 / $2,041.93 / $4,619.68
| Professional | | $1,874.95 | $2,041.93 | $4,619.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.45 / $2,171.29 / $2,750.00
| Professional | | $1,979.45 | $2,171.29 | $2,750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.88 / $2,038.70 / $4,224.66
| Professional | | $1,568.88 | $2,038.70 | $4,224.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.12 / $2,203.46 / $3,657.84
| Professional | | $1,708.12 | $2,203.46 | $3,657.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.26 / $1,883.10 / $3,399.20
| Professional | | $1,364.26 | $1,883.10 | $3,399.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.85 / $1,352.85 / $2,401.89
| Professional | | $1,352.85 | $1,352.85 | $2,401.89 |