- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.96 / $1,462.25 / $6,400.94
| Professional | | $1,209.96 | $1,462.25 | $6,400.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.47 / $1,321.62 / $1,600.00
| Professional | | $1,297.47 | $1,321.62 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.86 / $1,664.91 / $3,145.96
| Professional | | $1,173.86 | $1,664.91 | $3,145.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.94 / $1,683.70 / $2,713.06
| Professional | | $1,265.94 | $1,683.70 | $2,713.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.00 / $1,491.76 / $2,458.65
| Professional | | $1,072.00 | $1,491.76 | $2,458.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.02 / $1,455.83 / $1,802.57
| Professional | | $996.02 | $1,455.83 | $1,802.57 |