- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.57 / $1,251.54 / $2,572.21
| Professional | | $1,142.57 | $1,251.54 | $2,572.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.73 / $1,182.73 / $1,590.00
| Professional | | $1,182.73 | $1,182.73 | $1,590.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.75 / $1,280.64 / $2,576.13
| Professional | | $958.75 | $1,280.64 | $2,576.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.29 / $1,356.16 / $2,227.80
| Professional | | $1,051.29 | $1,356.16 | $2,227.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.42 / $1,248.48 / $2,517.92
| Professional | | $929.42 | $1,248.48 | $2,517.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.09 / $850.09 / $1,473.06
| Professional | | $850.09 | $850.09 | $1,473.06 |