- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,258.93 / $3,090.30
| Professional | | $1,023.29 | $1,258.93 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,621.81 / $2,398.83
| Professional | | $954.99 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,621.81 / $2,398.83
| Professional | | $1,258.93 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $2,630.27
| Professional | | $1,174.90 | $1,445.44 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $3,311.31
| Professional | | $1,096.48 | $1,513.56 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $2,344.23
| Professional | | $1,000.00 | $1,412.54 | $2,344.23 |