- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.72 / $1,179.53 / $1,838.79
| Professional | | $1,094.72 | $1,179.53 | $1,838.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.41 / $2,101.34 / $9,976.00
| Professional | | $1,167.41 | $2,101.34 | $9,976.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.52 / $2,077.32 / $3,378.67
| Professional | | $1,230.52 | $2,077.32 | $3,378.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,315.62 / $1,593.65 / $2,160.12
| Professional | | $1,315.62 | $1,593.65 | $2,160.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.36 / $2,821.67 / $3,722.23
| Professional | | $1,423.36 | $2,821.67 | $3,722.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.55 / $2,236.52 / $9,976.00
| Professional | | $1,314.55 | $2,236.52 | $9,976.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.76 / $1,859.16 / $3,880.57
| Professional | | $1,239.76 | $1,859.16 | $3,880.57 |