- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.54 / $2,065.96 / $2,128.15
| Professional | | $1,912.54 | $2,065.96 | $2,128.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.85 / $2,589.85 / $3,289.11
| Professional | | $2,589.85 | $2,589.85 | $3,289.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,583.77 / $2,174.05 / $4,332.68
| Professional | | $1,583.77 | $2,174.05 | $4,332.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,727.58 / $2,228.58 / $3,727.42
| Professional | | $1,727.58 | $2,228.58 | $3,727.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,339.81 / $2,219.06 / $4,321.60
| Professional | | $1,339.81 | $2,219.06 | $4,321.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.55 / $1,719.55 / $1,719.55
| Professional | | $1,719.55 | $1,719.55 | $1,719.55 |