- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,110.60 / $2,295.87 / $3,294.05
| Professional | | $2,110.60 | $2,295.87 | $3,294.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,119.31 / $2,429.32 / $2,776.72
| Professional | | $2,119.31 | $2,429.32 | $2,776.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,760.56 / $2,558.07 / $4,729.55
| Professional | | $1,760.56 | $2,558.07 | $4,729.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,931.72 / $2,491.92 / $4,093.80
| Professional | | $1,931.72 | $2,491.92 | $4,093.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.67 / $2,186.77 / $3,633.40
| Professional | | $1,628.67 | $2,186.77 | $3,633.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.25 / $1,763.25 / $2,706.18
| Professional | | $1,763.25 | $1,763.25 | $2,706.18 |