- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.77 / $1,461.98 / $1,590.28
| Professional | | $1,225.77 | $1,461.98 | $1,590.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.93 / $1,480.58 / $9,276.00
| Professional | | $1,327.93 | $1,480.58 | $9,276.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.35 / $2,710.49 / $4,205.75
| Professional | | $1,316.35 | $2,710.49 | $4,205.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,699.28 / $3,494.54 / $3,494.54
| Professional | | $2,699.28 | $3,494.54 | $3,494.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.46 / $2,283.69 / $4,230.93
| Professional | | $1,301.46 | $2,283.69 | $4,230.93 |