- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.79 / $1,286.79 / $6,399.35
| Professional | | $1,234.79 | $1,286.79 | $6,399.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.95 / $1,401.05 / $1,601.39
| Professional | | $1,096.95 | $1,401.05 | $1,601.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.56 / $1,628.27 / $3,772.25
| Professional | | $1,188.56 | $1,628.27 | $3,772.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.17 / $1,608.85 / $2,656.15
| Professional | | $1,247.17 | $1,608.85 | $2,656.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.80 / $1,468.31 / $2,624.12
| Professional | | $1,054.80 | $1,468.31 | $2,624.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.84 / $1,434.25 / $1,784.00
| Professional | | $962.84 | $1,434.25 | $1,784.00 |