- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.68 / $1,439.52 / $2,489.92
| Professional | | $1,151.68 | $1,439.52 | $2,489.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.21 / $1,810.52 / $2,077.51
| Professional | | $1,412.21 | $1,810.52 | $2,077.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,269.01 / $1,792.40 / $3,014.71
| Professional | | $1,269.01 | $1,792.40 | $3,014.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.02 / $1,944.00 / $11,498.48
| Professional | | $1,461.02 | $1,944.00 | $11,498.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.00 / $1,662.54 / $3,024.15
| Professional | | $1,344.00 | $1,662.54 | $3,024.15 |