- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.72 / $1,239.08 / $1,525.71
| Professional | | $1,094.72 | $1,239.08 | $1,525.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,273.21 / $1,589.37 / $2,193.23
| Professional | | $1,273.21 | $1,589.37 | $2,193.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.14 / $1,768.07 / $2,640.02
| Professional | | $1,181.14 | $1,768.07 | $2,640.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.40 / $1,657.29 / $2,542.37
| Professional | | $1,432.40 | $1,657.29 | $2,542.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.96 / $1,239.08 / $1,525.71
| Professional | | $966.96 | $1,239.08 | $1,525.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.54 / $1,649.62 / $2,228.81
| Professional | | $1,159.54 | $1,649.62 | $2,228.81 |