- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $2,691.53
| Professional | | $1,023.29 | $1,412.54 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,698.24 / $2,238.72
| Professional | | $1,023.29 | $1,698.24 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $2,630.27
| Professional | | $1,202.26 | $1,513.56 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,621.81 / $2,398.83
| Professional | | $1,318.26 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $3,235.94
| Professional | | $1,023.29 | $1,412.54 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $2,630.27
| Professional | | $1,096.48 | $1,584.89 | $2,630.27 |