- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,194.40 / $2,405.16 / $5,504.19
| Professional | | $2,194.40 | $2,405.16 | $5,504.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,321.75 / $2,574.00 / $3,650.00
| Professional | | $2,321.75 | $2,574.00 | $3,650.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,832.47 / $2,395.14 / $4,928.64
| Professional | | $1,832.47 | $2,395.14 | $4,928.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.59 / $2,585.92 / $4,287.60
| Professional | | $2,004.59 | $2,585.92 | $4,287.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,625.33 / $2,205.84 / $3,987.06
| Professional | | $1,625.33 | $2,205.84 | $3,987.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,586.12 / $1,586.12 / $2,811.47
| Professional | | $1,586.12 | $1,586.12 | $2,811.47 |