- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.88 / $1,334.37 / $3,331.05
| Professional | | $1,215.88 | $1,334.37 | $3,331.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.06 / $1,700.00 / $1,986.74
| Professional | | $1,648.06 | $1,700.00 | $1,986.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.41 / $1,698.90 / $3,518.09
| Professional | | $1,257.41 | $1,698.90 | $3,518.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.06 / $1,887.35 / $3,023.21
| Professional | | $1,463.06 | $1,887.35 | $3,023.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.32 / $1,431.04 / $2,657.72
| Professional | | $931.32 | $1,431.04 | $2,657.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.13 / $1,682.52 / $2,036.38
| Professional | | $1,154.13 | $1,682.52 | $2,036.38 |