- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.65 / $1,069.65 / $6,328.48
| Professional | | $1,069.65 | $1,069.65 | $6,328.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.72 / $1,753.50 / $2,338.00
| Professional | | $1,028.72 | $1,753.50 | $2,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,912.00 / $2,614.66 / $3,627.03
| Professional | | $1,912.00 | $2,614.66 | $3,627.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,483.64 / $2,453.71 / $3,336.84
| Professional | | $1,483.64 | $2,453.71 | $3,336.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,848.66 / $2,497.19 / $3,627.03
| Professional | | $1,848.66 | $2,497.19 | $3,627.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,483.64 / $2,556.33 / $3,195.53
| Professional | | $1,483.64 | $2,556.33 | $3,195.53 |