- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.14 / $1,703.77 / $7,423.79
| Professional | | $1,394.14 | $1,703.77 | $7,423.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.00 / $1,689.98 / $1,931.64
| Professional | | $1,410.00 | $1,689.98 | $1,931.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,397.08 / $1,973.82 / $3,673.06
| Professional | | $1,397.08 | $1,973.82 | $3,673.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.60 / $1,943.93 / $3,238.43
| Professional | | $1,461.60 | $1,943.93 | $3,238.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.01 / $1,696.22 / $2,822.18
| Professional | | $1,190.01 | $1,696.22 | $2,822.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.01 / $1,680.84 / $2,077.52
| Professional | | $1,106.01 | $1,680.84 | $2,077.52 |