- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.86 / $1,350.00 / $6,258.32
| Professional | | $1,158.86 | $1,350.00 | $6,258.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.38 / $1,421.33 / $1,750.00
| Professional | | $1,369.38 | $1,421.33 | $1,750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.99 / $1,685.23 / $3,686.53
| Professional | | $1,151.99 | $1,685.23 | $3,686.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.02 / $1,622.63 / $2,598.14
| Professional | | $1,220.02 | $1,622.63 | $2,598.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.07 / $1,347.16 / $2,390.09
| Professional | | $996.07 | $1,347.16 | $2,390.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.05 / $1,403.02 / $1,744.79
| Professional | | $947.05 | $1,403.02 | $1,744.79 |