- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.20 / $1,190.84 / $2,418.23
| Professional | | $1,147.20 | $1,190.84 | $2,418.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.45 / $1,293.45 / $1,730.00
| Professional | | $1,293.45 | $1,293.45 | $1,730.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.38 / $1,606.86 / $3,489.75
| Professional | | $1,125.38 | $1,606.86 | $3,489.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.80 / $1,535.88 / $2,457.41
| Professional | | $1,154.80 | $1,535.88 | $2,457.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,002.06 / $1,465.49 / $2,587.87
| Professional | | $1,002.06 | $1,465.49 | $2,587.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.45 / $1,328.02 / $1,652.09
| Professional | | $902.45 | $1,328.02 | $1,652.09 |