- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.25 / $1,162.96 / $5,653.45
| Professional | | $1,090.25 | $1,162.96 | $5,653.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,237.18 / $1,326.93 / $1,710.00
| Professional | | $1,237.18 | $1,326.93 | $1,710.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.02 / $1,541.63 / $3,329.76
| Professional | | $1,079.02 | $1,541.63 | $3,329.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.00 / $1,466.99 / $2,344.46
| Professional | | $1,103.00 | $1,466.99 | $2,344.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.84 / $1,356.67 / $2,159.35
| Professional | | $946.84 | $1,356.67 | $2,159.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.20 / $1,268.45 / $1,577.57
| Professional | | $962.20 | $1,268.45 | $1,577.57 |