- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.80 / $1,709.55 / $7,944.94
| Professional | | $1,472.80 | $1,709.55 | $7,944.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.34 / $1,800.06 / $2,090.00
| Professional | | $1,732.34 | $1,800.06 | $2,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,476.02 / $2,041.06 / $4,668.83
| Professional | | $1,476.02 | $2,041.06 | $4,668.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.94 / $2,056.10 / $3,289.47
| Professional | | $1,545.94 | $2,056.10 | $3,289.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.35 / $1,844.28 / $3,734.78
| Professional | | $1,317.35 | $1,844.28 | $3,734.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.52 / $1,777.83 / $2,211.66
| Professional | | $1,203.52 | $1,777.83 | $2,211.66 |