- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.92 / $1,169.11 / $2,444.00
| Professional | | $1,047.92 | $1,169.11 | $2,444.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.65 / $1,454.34 / $2,015.84
| Professional | | $1,181.65 | $1,454.34 | $2,015.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.70 / $1,522.58 / $2,151.00
| Professional | | $1,034.70 | $1,522.58 | $2,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.12 / $1,309.58 / $3,475.29
| Professional | | $11.12 | $1,309.58 | $3,475.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.34 / $1,113.08 / $4,739.03
| Professional | | $8.34 | $1,113.08 | $4,739.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.50 / $1,423.46 / $2,225.57
| Professional | | $1,087.50 | $1,423.46 | $2,225.57 |