- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,659.59 / $1,862.09
| Professional | | $1,479.11 | $1,659.59 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,778.28 / $2,041.74
| Professional | | $1,584.89 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,570.40 / $3,311.31
| Professional | | $2,238.72 | $2,570.40 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $1,659.59
| Professional | | $933.25 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Professional | | $1,096.48 | $1,096.48 | $1,096.48 |