- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,757.82 / $1,915.69 / $4,148.60
| Professional | | $1,757.82 | $1,915.69 | $4,148.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,856.53 / $2,054.82 / $2,600.00
| Professional | | $1,856.53 | $2,054.82 | $2,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.10 / $1,941.21 / $3,960.81
| Professional | | $1,471.10 | $1,941.21 | $3,960.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.84 / $2,066.37 / $3,430.69
| Professional | | $1,601.84 | $2,066.37 | $3,430.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.65 / $1,832.29 / $3,422.81
| Professional | | $1,357.65 | $1,832.29 | $3,422.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.36 / $1,263.36 / $2,252.30
| Professional | | $1,263.36 | $1,263.36 | $2,252.30 |