- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.72 / $1,327.28 / $1,800.59
| Professional | | $1,082.72 | $1,327.28 | $1,800.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.57 / $1,982.53 / $2,862.48
| Professional | | $1,171.57 | $1,982.53 | $2,862.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.15 / $1,630.98 / $2,038.73
| Professional | | $1,359.15 | $1,630.98 | $2,038.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.85 / $1,852.03 / $3,193.54
| Professional | | $1,312.85 | $1,852.03 | $3,193.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.12 / $1,730.47 / $3,075.75
| Professional | | $1,323.12 | $1,730.47 | $3,075.75 |