- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,197.92 / $1,438.19 / $6,292.58
| Professional | | $1,197.92 | $1,438.19 | $6,292.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,340.00 / $1,458.84 / $1,667.45
| Professional | | $1,340.00 | $1,458.84 | $1,667.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.11 / $1,736.87 / $3,160.55
| Professional | | $1,169.11 | $1,736.87 | $3,160.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.29 / $1,698.80 / $2,726.80
| Professional | | $1,277.29 | $1,698.80 | $2,726.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.22 / $1,491.63 / $2,513.65
| Professional | | $1,068.22 | $1,491.63 | $2,513.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.59 / $1,468.88 / $1,792.16
| Professional | | $999.59 | $1,468.88 | $1,792.16 |