- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.59 / $1,962.92 / $4,251.88
| Professional | | $1,464.59 | $1,962.92 | $4,251.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,128.91 / $2,433.33
| Professional | | $2,100.00 | $2,128.91 | $2,433.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,561.58 / $2,484.83 / $4,958.22
| Professional | | $1,561.58 | $2,484.83 | $4,958.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,042.93 / $2,635.38 / $4,282.20
| Professional | | $2,042.93 | $2,635.38 | $4,282.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.94 / $2,123.04 / $3,642.48
| Professional | | $1,533.94 | $2,123.04 | $3,642.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.08 / $2,349.37 / $2,815.53
| Professional | | $1,567.08 | $2,349.37 | $2,815.53 |