- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.79 / $1,205.82 / $3,229.31
| Professional | | $1,103.79 | $1,205.82 | $3,229.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.42 / $1,139.42 / $1,590.00
| Professional | | $1,139.42 | $1,139.42 | $1,590.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.17 / $1,233.32 / $2,483.48
| Professional | | $924.17 | $1,233.32 | $2,483.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.33 / $1,307.20 / $2,146.00
| Professional | | $1,013.33 | $1,307.20 | $2,146.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.23 / $1,219.69 / $2,419.46
| Professional | | $896.23 | $1,219.69 | $2,419.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.52 / $805.52 / $1,419.89
| Professional | | $805.52 | $805.52 | $1,419.89 |