- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,887.31 / $2,055.11 / $3,276.13
| Professional | | $1,887.31 | $2,055.11 | $3,276.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,804.63 / $2,045.71 / $2,338.25
| Professional | | $1,804.63 | $2,045.71 | $2,338.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,574.97 / $2,112.71 / $4,231.70
| Professional | | $1,574.97 | $2,112.71 | $4,231.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,727.92 / $2,229.02 / $3,662.29
| Professional | | $1,727.92 | $2,229.02 | $3,662.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.79 / $1,953.92 / $3,467.35
| Professional | | $1,482.79 | $1,953.92 | $3,467.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.43 / $1,396.43 / $2,420.73
| Professional | | $1,396.43 | $1,396.43 | $2,420.73 |