- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.90 / $1,295.96 / $6,437.80
| Professional | | $1,242.90 | $1,295.96 | $6,437.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.91 / $1,403.91 / $1,890.00
| Professional | | $1,403.91 | $1,403.91 | $1,890.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.58 / $1,640.89 / $3,798.35
| Professional | | $1,181.58 | $1,640.89 | $3,798.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.93 / $1,671.72 / $2,672.96
| Professional | | $1,256.93 | $1,671.72 | $2,672.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.20 / $1,556.46 / $2,816.56
| Professional | | $1,068.20 | $1,556.46 | $2,816.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.57 / $1,445.47 / $1,797.78
| Professional | | $976.57 | $1,445.47 | $1,797.78 |