- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.54 / $1,251.52 / $6,229.48
| Professional | | $1,201.54 | $1,251.52 | $6,229.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.60 / $1,414.08 / $1,650.00
| Professional | | $1,361.60 | $1,414.08 | $1,650.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.50 / $1,601.77 / $3,667.71
| Professional | | $1,157.50 | $1,601.77 | $3,667.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.58 / $1,615.39 / $2,583.13
| Professional | | $1,214.58 | $1,615.39 | $2,583.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.59 / $1,433.19 / $2,380.04
| Professional | | $1,027.59 | $1,433.19 | $2,380.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.84 / $1,396.77 / $1,737.29
| Professional | | $989.84 | $1,396.77 | $1,737.29 |