- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,589.29 / $1,768.40 / $2,909.29
| Professional | | $1,589.29 | $1,768.40 | $2,909.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.97 / $1,635.97 / $2,260.00
| Professional | | $1,635.97 | $1,635.97 | $2,260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.53 / $1,770.70 / $3,664.63
| Professional | | $1,359.53 | $1,770.70 | $3,664.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.12 / $1,909.35 / $3,172.90
| Professional | | $1,480.12 | $1,909.35 | $3,172.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.34 / $1,628.06 / $2,941.58
| Professional | | $1,252.34 | $1,628.06 | $2,941.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.58 / $1,160.58 / $2,081.28
| Professional | | $1,160.58 | $1,160.58 | $2,081.28 |