- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.59 / $1,833.32 / $3,547.41
| Professional | | $1,463.59 | $1,833.32 | $3,547.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,735.70 / $1,735.70 / $2,240.00
| Professional | | $1,735.70 | $1,735.70 | $2,240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.71 / $1,882.84 / $3,774.52
| Professional | | $1,404.71 | $1,882.84 | $3,774.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.72 / $1,987.53 / $3,267.16
| Professional | | $1,540.72 | $1,987.53 | $3,267.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.18 / $1,813.30 / $2,894.54
| Professional | | $1,318.18 | $1,813.30 | $2,894.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.26 / $1,219.26 / $2,158.73
| Professional | | $1,219.26 | $1,219.26 | $2,158.73 |