- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,873.00 / $2,326.82 / $5,665.16
| Professional | | $1,873.00 | $2,326.82 | $5,665.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.96 / $2,542.13 / $2,905.66
| Professional | | $2,193.96 | $2,542.13 | $2,905.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.92 / $2,985.02 / $5,898.20
| Professional | | $2,084.92 | $2,985.02 | $5,898.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,424.84 / $3,128.04 / $5,092.53
| Professional | | $2,424.84 | $3,128.04 | $5,092.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.67 / $2,663.68 / $4,758.35
| Professional | | $1,906.67 | $2,663.68 | $4,758.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.64 / $2,788.57 / $3,339.23
| Professional | | $2,064.64 | $2,788.57 | $3,339.23 |