- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.91 / $2,265.86 / $4,913.45
| Professional | | $1,658.91 | $2,265.86 | $4,913.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,211.86 / $2,388.53 / $2,730.08
| Professional | | $2,211.86 | $2,388.53 | $2,730.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.56 / $2,248.56 / $4,685.55
| Professional | | $1,743.56 | $2,248.56 | $4,685.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.37 / $2,457.92 / $4,072.15
| Professional | | $1,905.37 | $2,457.92 | $4,072.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,598.87 / $2,081.38 / $4,209.26
| Professional | | $1,598.87 | $2,081.38 | $4,209.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.92 / $1,493.92 / $2,673.24
| Professional | | $1,493.92 | $1,493.92 | $2,673.24 |