- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.08 / $1,437.98 / $1,457.41
| Professional | | $1,263.08 | $1,437.98 | $1,457.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,554.57 / $1,787.75 / $2,038.03
| Professional | | $1,554.57 | $1,787.75 | $2,038.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.90 / $1,029.90 / $1,029.90
| Professional | | $1,029.90 | $1,029.90 | $1,029.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.21 / $2,234.69 / $2,914.82
| Professional | | $1,943.21 | $2,234.69 | $2,914.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $893.88 / $1,768.28
| Professional | | $816.15 | $893.88 | $1,768.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.61 / $1,544.85 / $1,544.85
| Professional | | $971.61 | $1,544.85 | $1,544.85 |