- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.84 / $1,927.26 / $5,116.30
| Professional | | $1,761.84 | $1,927.26 | $5,116.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,647.67 / $1,647.67 / $1,925.59
| Professional | | $1,647.67 | $1,647.67 | $1,925.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.80 / $1,918.60 / $3,964.59
| Professional | | $1,471.80 | $1,918.60 | $3,964.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,602.79 / $2,067.60 / $3,431.16
| Professional | | $1,602.79 | $2,067.60 | $3,431.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.44 / $1,767.69 / $2,992.51
| Professional | | $1,310.44 | $1,767.69 | $2,992.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.00 / $1,276.00 / $2,253.59
| Professional | | $1,276.00 | $1,276.00 | $2,253.59 |