- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,131.86 / $2,337.46 / $5,827.94
| Professional | | $2,131.86 | $2,337.46 | $5,827.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,256.53 / $2,502.69 / $3,450.00
| Professional | | $2,256.53 | $2,502.69 | $3,450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.99 / $2,389.48 / $4,792.13
| Professional | | $1,779.99 | $2,389.48 | $4,792.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.87 / $2,511.46 / $4,169.22
| Professional | | $1,946.87 | $2,511.46 | $4,169.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,582.61 / $2,128.90 / $3,866.71
| Professional | | $1,582.61 | $2,128.90 | $3,866.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.83 / $1,536.83 / $2,730.59
| Professional | | $1,536.83 | $1,536.83 | $2,730.59 |