- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.92 / $1,206.82 / $6,012.65
| Professional | | $1,158.92 | $1,206.82 | $6,012.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.53 / $1,311.53 / $1,625.00
| Professional | | $1,311.53 | $1,311.53 | $1,625.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.78 / $1,527.32 / $3,538.01
| Professional | | $1,110.78 | $1,527.32 | $3,538.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.31 / $1,557.84 / $2,492.36
| Professional | | $1,171.31 | $1,557.84 | $2,492.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.31 / $1,395.88 / $2,402.38
| Professional | | $991.31 | $1,395.88 | $2,402.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.74 / $1,347.01 / $1,675.57
| Professional | | $923.74 | $1,347.01 | $1,675.57 |