- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.06 / $2,117.55 / $4,497.53
| Professional | | $1,932.06 | $2,117.55 | $4,497.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,927.24 / $1,927.24 / $2,850.00
| Professional | | $1,927.24 | $1,927.24 | $2,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,612.96 / $2,085.48 / $4,338.22
| Professional | | $1,612.96 | $2,085.48 | $4,338.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.66 / $2,276.41 / $3,775.17
| Professional | | $1,764.66 | $2,276.41 | $3,775.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.96 / $1,941.54 / $3,509.33
| Professional | | $1,508.96 | $1,941.54 | $3,509.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.43 / $1,396.43 / $2,474.79
| Professional | | $1,396.43 | $1,396.43 | $2,474.79 |