- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,723.05 / $2,210.92 / $4,894.05
| Professional | | $1,723.05 | $2,210.92 | $4,894.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.05 / $2,327.40 / $2,814.41
| Professional | | $2,157.05 | $2,327.40 | $2,814.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,701.31 / $2,183.76 / $4,569.00
| Professional | | $1,701.31 | $2,183.76 | $4,569.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,859.81 / $2,399.15 / $3,973.62
| Professional | | $1,859.81 | $2,399.15 | $3,973.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.02 / $2,082.17 / $3,677.21
| Professional | | $1,539.02 | $2,082.17 | $3,677.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.90 / $1,461.90 / $2,608.96
| Professional | | $1,461.90 | $1,461.90 | $2,608.96 |