- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.65 / $1,433.97 / $2,259.51
| Professional | | $1,316.65 | $1,433.97 | $2,259.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,397.66 / $1,516.32 / $1,760.00
| Professional | | $1,397.66 | $1,516.32 | $1,760.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.28 / $1,418.05 / $2,978.03
| Professional | | $1,107.28 | $1,418.05 | $2,978.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.81 / $1,554.20 / $2,581.41
| Professional | | $1,204.81 | $1,554.20 | $2,581.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.50 / $1,427.31 / $2,222.39
| Professional | | $960.50 | $1,427.31 | $2,222.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.25 / $952.25 / $1,694.46
| Professional | | $952.25 | $952.25 | $1,694.46 |