- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,692.68 / $2,016.12 / $3,753.89
| Professional | | $1,692.68 | $2,016.12 | $3,753.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,948.44 / $2,005.63 / $2,292.44
| Professional | | $1,948.44 | $2,005.63 | $2,292.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.76 / $2,071.86 / $4,151.80
| Professional | | $1,545.76 | $2,071.86 | $4,151.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.92 / $2,187.73 / $3,595.00
| Professional | | $1,695.92 | $2,187.73 | $3,595.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.56 / $1,917.84 / $3,403.94
| Professional | | $1,441.56 | $1,917.84 | $3,403.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.79 / $1,416.79 / $2,375.84
| Professional | | $1,416.79 | $1,416.79 | $2,375.84 |