- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,642.23 / $2,108.77 / $5,651.50
| Professional | | $1,642.23 | $2,108.77 | $5,651.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.10 / $2,222.17 / $2,539.94
| Professional | | $2,049.10 | $2,222.17 | $2,539.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.01 / $2,092.23 / $4,350.06
| Professional | | $1,618.01 | $2,092.23 | $4,350.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,770.27 / $2,283.65 / $3,786.55
| Professional | | $1,770.27 | $2,283.65 | $3,786.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.42 / $1,947.37 / $3,297.29
| Professional | | $1,417.42 | $1,947.37 | $3,297.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.59 / $1,400.59 / $2,482.59
| Professional | | $1,400.59 | $1,400.59 | $2,482.59 |