- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.66 / $1,244.57 / $2,574.98
| Professional | | $1,141.66 | $1,244.57 | $2,574.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.72 / $1,240.50 / $1,750.00
| Professional | | $1,202.72 | $1,240.50 | $1,750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.77 / $1,292.98 / $2,562.63
| Professional | | $953.77 | $1,292.98 | $2,562.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,046.02 / $1,349.37 / $2,217.67
| Professional | | $1,046.02 | $1,349.37 | $2,217.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.81 / $1,251.64 / $2,094.40
| Professional | | $898.81 | $1,251.64 | $2,094.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.84 / $888.84 / $1,465.61
| Professional | | $888.84 | $888.84 | $1,465.61 |