- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.72 / $1,286.91 / $1,286.91
| Professional | | $1,094.72 | $1,286.91 | $1,286.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.30 / $1,452.29 / $1,594.63
| Professional | | $1,161.30 | $1,452.29 | $1,594.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.76 / $1,602.45 / $2,033.59
| Professional | | $1,175.76 | $1,602.45 | $2,033.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.16 / $1,373.62 / $9,976.00
| Professional | | $1,064.16 | $1,373.62 | $9,976.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.56 / $1,292.14 / $1,782.87
| Professional | | $1,001.56 | $1,292.14 | $1,782.87 |