- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.66 / $1,425.86 / $2,965.50
| Professional | | $1,299.66 | $1,425.86 | $2,965.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.62 / $1,530.09 / $1,980.00
| Professional | | $1,379.62 | $1,530.09 | $1,980.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.29 / $1,459.19 / $2,929.77
| Professional | | $1,087.29 | $1,459.19 | $2,929.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.35 / $1,532.98 / $2,546.61
| Professional | | $1,188.35 | $1,532.98 | $2,546.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.54 / $1,366.56 / $2,352.44
| Professional | | $1,000.54 | $1,366.56 | $2,352.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.25 / $934.25 / $1,667.21
| Professional | | $934.25 | $934.25 | $1,667.21 |