- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.02 / $1,034.53 / $6,388.59
| Professional | | $1,014.02 | $1,034.53 | $6,388.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.51 / $1,368.36 / $1,600.00
| Professional | | $1,349.51 | $1,368.36 | $1,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.50 / $1,646.82 / $3,134.51
| Professional | | $1,115.50 | $1,646.82 | $3,134.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.03 / $1,626.73 / $2,714.45
| Professional | | $1,261.03 | $1,626.73 | $2,714.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.07 / $1,469.23 / $2,480.67
| Professional | | $1,076.07 | $1,469.23 | $2,480.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.72 / $1,450.18 / $1,790.05
| Professional | | $1,167.72 | $1,450.18 | $1,790.05 |