- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.97 / $1,701.64 / $2,277.77
| Professional | | $1,557.97 | $1,701.64 | $2,277.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.00 / $1,611.29 / $1,841.70
| Professional | | $1,540.00 | $1,611.29 | $1,841.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.30 / $1,746.38 / $3,501.90
| Professional | | $1,304.30 | $1,746.38 | $3,501.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.81 / $1,845.74 / $3,030.71
| Professional | | $1,430.81 | $1,845.74 | $3,030.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.84 / $1,705.17 / $2,865.47
| Professional | | $1,224.84 | $1,705.17 | $2,865.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.72 / $1,131.72 / $2,004.50
| Professional | | $1,131.72 | $1,131.72 | $2,004.50 |