- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,625.09 / $2,225.83 / $4,585.54
| Professional | | $1,625.09 | $2,225.83 | $4,585.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,163.92 / $2,368.46 / $2,707.17
| Professional | | $2,163.92 | $2,368.46 | $2,707.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.75 / $2,242.28 / $4,593.35
| Professional | | $1,640.75 | $2,242.28 | $4,593.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,868.37 / $2,410.19 / $3,996.40
| Professional | | $1,868.37 | $2,410.19 | $3,996.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.86 / $1,974.67 / $3,712.71
| Professional | | $1,527.86 | $1,974.67 | $3,712.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.30 / $1,477.30 / $2,620.53
| Professional | | $1,477.30 | $1,477.30 | $2,620.53 |