- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.54 / $2,035.93 / $9,780.21
| Professional | | $1,841.54 | $2,035.93 | $9,780.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.00 / $2,009.33 / $2,296.67
| Professional | | $1,725.00 | $2,009.33 | $2,296.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.85 / $2,487.33 / $4,815.31
| Professional | | $1,762.85 | $2,487.33 | $4,815.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.95 / $2,566.83 / $4,213.02
| Professional | | $1,929.95 | $2,566.83 | $4,213.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.21 / $2,258.80 / $3,740.01
| Professional | | $1,641.21 | $2,258.80 | $3,740.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,677.92 / $2,219.44 / $2,745.90
| Professional | | $1,677.92 | $2,219.44 | $2,745.90 |