- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.30 / $1,245.24 / $5,767.99
| Professional | | $1,068.30 | $1,245.24 | $5,767.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.18 / $1,290.00 / $1,496.44
| Professional | | $1,261.18 | $1,290.00 | $1,496.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.60 / $1,466.23 / $3,395.74
| Professional | | $1,082.60 | $1,466.23 | $3,395.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.78 / $1,494.63 / $2,391.05
| Professional | | $1,123.78 | $1,494.63 | $2,391.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.85 / $1,252.22 / $2,364.82
| Professional | | $956.85 | $1,252.22 | $2,364.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.49 / $1,292.34 / $1,607.51
| Professional | | $894.49 | $1,292.34 | $1,607.51 |