- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.72 / $1,153.41 / $1,838.79
| Professional | | $1,094.72 | $1,153.41 | $1,838.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.03 / $3,209.67 / $4,188.14
| Professional | | $2,023.03 | $3,209.67 | $4,188.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,099.52 / $3,344.49 / $4,967.07
| Professional | | $2,099.52 | $3,344.49 | $4,967.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.84 / $2,990.20 / $4,555.10
| Professional | | $1,900.84 | $2,990.20 | $4,555.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.98 / $2,379.96 / $4,807.77
| Professional | | $1,308.98 | $2,379.96 | $4,807.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.51 / $2,259.27 / $4,569.62
| Professional | | $1,289.51 | $2,259.27 | $4,569.62 |