- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.91 / $1,275.89 / $2,581.36
| Professional | | $1,166.91 | $1,275.89 | $2,581.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.83 / $1,268.16 / $1,990.00
| Professional | | $1,121.83 | $1,268.16 | $1,990.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.83 / $1,306.06 / $2,625.16
| Professional | | $926.83 | $1,306.06 | $2,625.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.92 / $1,382.78 / $2,268.96
| Professional | | $1,071.92 | $1,382.78 | $2,268.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $859.88 / $1,125.49 / $2,138.96
| Professional | | $859.88 | $1,125.49 | $2,138.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.32 / $868.32 / $1,501.92
| Professional | | $868.32 | $868.32 | $1,501.92 |