- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.55 / $1,245.55 / $1,401.81
| Professional | | $1,245.55 | $1,245.55 | $1,401.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.38 / $1,293.18 / $1,976.09
| Professional | | $1,168.38 | $1,293.18 | $1,976.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.08 / $1,448.85 / $2,075.73
| Professional | | $1,183.08 | $1,448.85 | $2,075.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.60 / $1,384.00 / $2,123.14
| Professional | | $1,074.60 | $1,384.00 | $2,123.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.31 / $1,245.55 / $1,401.81
| Professional | | $1,148.31 | $1,245.55 | $1,401.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.60 / $1,538.90 / $1,915.03
| Professional | | $1,074.60 | $1,538.90 | $1,915.03 |