- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.90 / $1,293.57 / $3,360.56
| Professional | | $1,274.90 | $1,293.57 | $3,360.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.66 / $1,756.66 / $2,350.00
| Professional | | $1,756.66 | $1,756.66 | $2,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.95 / $1,937.06 / $3,922.45
| Professional | | $1,327.95 | $1,937.06 | $3,922.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,593.05 / $2,118.76 / $3,389.16
| Professional | | $1,593.05 | $2,118.76 | $3,389.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.58 / $1,803.68 / $3,105.92
| Professional | | $1,242.58 | $1,803.68 | $3,105.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.12 / $1,832.01 / $2,260.56
| Professional | | $1,344.12 | $1,832.01 | $2,260.56 |