- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.91 / $1,057.11 / $2,958.20
| Professional | | $1,004.91 | $1,057.11 | $2,958.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.00 / $1,369.82 / $1,565.71
| Professional | | $1,170.00 | $1,369.82 | $1,565.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.66 / $1,443.72 / $3,087.19
| Professional | | $1,061.66 | $1,443.72 | $3,087.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.47 / $1,447.99 / $2,405.61
| Professional | | $1,122.47 | $1,447.99 | $2,405.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.75 / $1,283.77 / $2,443.94
| Professional | | $904.75 | $1,283.77 | $2,443.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.37 / $881.37 / $1,579.04
| Professional | | $881.37 | $881.37 | $1,579.04 |