- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.98 / $1,148.47 / $3,718.60
| Professional | | $1,040.98 | $1,148.47 | $3,718.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.08 / $1,209.35 / $1,520.00
| Professional | | $1,165.08 | $1,209.35 | $1,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $999.22 / $1,355.80 / $3,136.73
| Professional | | $999.22 | $1,355.80 | $3,136.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.75 / $1,381.54 / $2,210.63
| Professional | | $1,038.75 | $1,381.54 | $2,210.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.45 / $1,207.31 / $2,034.52
| Professional | | $877.45 | $1,207.31 | $2,034.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.70 / $1,194.56 / $1,485.45
| Professional | | $844.70 | $1,194.56 | $1,485.45 |