- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.91 / $1,282.30 / $5,596.47
| Professional | | $1,058.91 | $1,282.30 | $5,596.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.01 / $1,159.07 / $1,400.00
| Professional | | $1,138.01 | $1,159.07 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.65 / $1,453.51 / $2,755.89
| Professional | | $1,020.65 | $1,453.51 | $2,755.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.73 / $1,473.28 / $2,378.13
| Professional | | $1,107.73 | $1,473.28 | $2,378.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.19 / $1,220.95 / $2,147.26
| Professional | | $937.19 | $1,220.95 | $2,147.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.69 / $1,273.89 / $1,577.22
| Professional | | $860.69 | $1,273.89 | $1,577.22 |