- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.77 / $2,148.96 / $2,370.77
| Professional | | $1,950.77 | $2,148.96 | $2,370.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,731.12 / $1,731.12 / $2,286.31
| Professional | | $1,731.12 | $1,731.12 | $2,286.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.47 / $2,202.84 / $4,459.53
| Professional | | $1,648.47 | $2,202.84 | $4,459.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.72 / $2,329.38 / $3,861.49
| Professional | | $1,805.72 | $2,329.38 | $3,861.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.40 / $1,978.49 / $3,562.94
| Professional | | $1,536.40 | $1,978.49 | $3,562.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.82 / $1,411.82 / $2,529.78
| Professional | | $1,411.82 | $1,411.82 | $2,529.78 |