- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.46 / $1,203.66 / $5,993.83
| Professional | | $1,155.46 | $1,203.66 | $5,993.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.53 / $1,360.02 / $1,600.00
| Professional | | $1,310.53 | $1,360.02 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.13 / $1,522.57 / $3,527.51
| Professional | | $1,107.13 | $1,522.57 | $3,527.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.46 / $1,552.72 / $2,485.00
| Professional | | $1,167.46 | $1,552.72 | $2,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.42 / $1,362.13 / $2,289.87
| Professional | | $988.42 | $1,362.13 | $2,289.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.38 / $1,342.58 / $1,670.22
| Professional | | $908.38 | $1,342.58 | $1,670.22 |