- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.74 / $1,461.56 / $2,977.56
| Professional | | $1,331.74 | $1,461.56 | $2,977.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.56 / $1,530.84 / $1,990.00
| Professional | | $1,424.56 | $1,530.84 | $1,990.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.98 / $1,431.81 / $3,011.71
| Professional | | $1,121.98 | $1,431.81 | $3,011.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.32 / $1,580.66 / $2,614.94
| Professional | | $1,225.32 | $1,580.66 | $2,614.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.20 / $1,333.62 / $2,587.21
| Professional | | $997.20 | $1,333.62 | $2,587.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.99 / $957.99 / $1,719.51
| Professional | | $957.99 | $957.99 | $1,719.51 |