- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.73 / $1,389.98 / $2,885.12
| Professional | | $1,275.73 | $1,389.98 | $2,885.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.41 / $1,317.41 / $1,790.00
| Professional | | $1,317.41 | $1,317.41 | $1,790.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.13 / $1,428.61 / $2,860.44
| Professional | | $1,066.13 | $1,428.61 | $2,860.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.99 / $1,509.29 / $2,477.02
| Professional | | $1,169.99 | $1,509.29 | $2,477.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.20 / $1,360.63 / $2,342.23
| Professional | | $1,002.20 | $1,360.63 | $2,342.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.40 / $945.40 / $1,638.76
| Professional | | $945.40 | $945.40 | $1,638.76 |