- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.75 / $2,150.92 / $4,316.89
| Professional | | $1,681.75 | $2,150.92 | $4,316.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.71 / $2,289.78 / $2,617.23
| Professional | | $2,092.71 | $2,289.78 | $2,617.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.77 / $2,155.91 / $4,439.67
| Professional | | $1,651.77 | $2,155.91 | $4,439.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.82 / $2,330.80 / $3,863.89
| Professional | | $1,806.82 | $2,330.80 | $3,863.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.64 / $2,017.79 / $3,362.46
| Professional | | $1,523.64 | $2,017.79 | $3,362.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.47 / $1,427.47 / $2,534.07
| Professional | | $1,427.47 | $1,427.47 | $2,534.07 |