- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.72 / $1,153.41 / $1,202.88
| Professional | | $1,094.72 | $1,153.41 | $1,202.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,284.90 / $2,513.51 / $2,947.21
| Professional | | $2,284.90 | $2,513.51 | $2,947.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.57 / $2,832.13 / $3,772.40
| Professional | | $1,417.57 | $2,832.13 | $3,772.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.95 / $2,165.71 / $3,118.13
| Professional | | $1,251.95 | $2,165.71 | $3,118.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.95 / $2,165.71 / $2,754.29
| Professional | | $1,251.95 | $2,165.71 | $2,754.29 |