- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.81 / $1,209.31 / $1,805.47
| Professional | | $1,072.81 | $1,209.31 | $1,805.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.86 / $1,598.26 / $4,088.32
| Professional | | $1,355.86 | $1,598.26 | $4,088.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.44 / $1,859.08 / $2,663.47
| Professional | | $1,065.44 | $1,859.08 | $2,663.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.44 / $1,825.00 / $2,663.47
| Professional | | $1,065.44 | $1,825.00 | $2,663.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.37 / $1,624.39 / $4,722.22
| Professional | | $1,444.37 | $1,624.39 | $4,722.22 |