- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.15 / $1,217.18 / $2,620.46
| Professional | | $1,113.15 | $1,217.18 | $2,620.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.38 / $1,195.38 / $1,590.00
| Professional | | $1,195.38 | $1,195.38 | $1,590.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.33 / $1,368.46 / $2,506.89
| Professional | | $932.33 | $1,368.46 | $2,506.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.03 / $1,318.42 / $2,165.64
| Professional | | $1,022.03 | $1,318.42 | $2,165.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.54 / $1,217.04 / $1,910.22
| Professional | | $902.54 | $1,217.04 | $1,910.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.87 / $918.87 / $1,432.20
| Professional | | $918.87 | $918.87 | $1,432.20 |