- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,777.96 / $2,040.41 / $4,528.21
| Professional | | $1,777.96 | $2,040.41 | $4,528.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,978.75 / $2,158.38 / $3,000.00
| Professional | | $1,978.75 | $2,158.38 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.03 / $2,086.28 / $4,188.26
| Professional | | $1,559.03 | $2,086.28 | $4,188.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,703.54 / $2,197.57 / $3,641.06
| Professional | | $1,703.54 | $2,197.57 | $3,641.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.85 / $1,848.44 / $3,366.36
| Professional | | $1,350.85 | $1,848.44 | $3,366.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.67 / $1,338.67 / $2,390.21
| Professional | | $1,338.67 | $1,338.67 | $2,390.21 |