- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.72 / $1,179.53 / $1,298.70
| Professional | | $1,094.72 | $1,179.53 | $1,298.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,179.95 / $1,309.07 / $1,439.98
| Professional | | $1,179.95 | $1,309.07 | $1,439.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.55 / $1,604.60 / $3,008.96
| Professional | | $1,085.55 | $1,604.60 | $3,008.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.11 / $1,537.27 / $2,447.16
| Professional | | $1,191.11 | $1,537.27 | $2,447.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.02 / $1,300.92 / $2,561.85
| Professional | | $972.02 | $1,300.92 | $2,561.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,183.44 / $1,370.43 / $1,704.76
| Professional | | $1,183.44 | $1,370.43 | $1,704.76 |