- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.64 / $1,667.73 / $8,015.06
| Professional | | $1,551.64 | $1,667.73 | $8,015.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.00 / $1,814.22 / $2,073.66
| Professional | | $1,700.00 | $1,814.22 | $2,073.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.60 / $2,137.17 / $4,214.18
| Professional | | $1,471.60 | $2,137.17 | $4,214.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.75 / $2,286.56 / $3,641.07
| Professional | | $1,737.75 | $2,286.56 | $3,641.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.86 / $1,904.40 / $3,855.83
| Professional | | $1,350.86 | $1,904.40 | $3,855.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.60 / $1,998.41 / $2,394.71
| Professional | | $1,455.60 | $1,998.41 | $2,394.71 |