- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,336.85 / $1,437.41 / $5,580.00
| Professional | | $1,336.85 | $1,437.41 | $5,580.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.84 / $1,560.84 / $1,784.05
| Professional | | $1,560.84 | $1,560.84 | $1,784.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.03 / $1,840.01 / $3,631.36
| Professional | | $1,288.03 | $1,840.01 | $3,631.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.65 / $1,990.54 / $3,138.11
| Professional | | $1,496.65 | $1,990.54 | $3,138.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.94 / $1,628.48 / $2,925.00
| Professional | | $1,171.94 | $1,628.48 | $2,925.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.77 / $1,721.15 / $2,062.96
| Professional | | $1,268.77 | $1,721.15 | $2,062.96 |