- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.93 / $1,596.16 / $7,572.89
| Professional | | $1,512.93 | $1,596.16 | $7,572.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.00 / $1,628.22 / $1,861.05
| Professional | | $1,510.00 | $1,628.22 | $1,861.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.34 / $1,922.55 / $4,735.05
| Professional | | $1,320.34 | $1,922.55 | $4,735.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.70 / $2,061.10 / $3,309.56
| Professional | | $1,549.70 | $2,061.10 | $3,309.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.51 / $1,835.75 / $3,432.62
| Professional | | $1,250.51 | $1,835.75 | $3,432.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.69 / $1,782.16 / $2,172.00
| Professional | | $1,286.69 | $1,782.16 | $2,172.00 |