- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.91 / $1,412.33 / $1,853.92
| Professional | | $1,149.91 | $1,412.33 | $1,853.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.38 / $1,966.96 / $2,655.39
| Professional | | $1,199.38 | $1,966.96 | $2,655.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.76 / $1,707.31 / $2,134.14
| Professional | | $1,422.76 | $1,707.31 | $2,134.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.89 / $1,895.99 / $3,272.35
| Professional | | $1,359.89 | $1,895.99 | $3,272.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.06 / $1,817.79 / $3,188.59
| Professional | | $1,359.06 | $1,817.79 | $3,188.59 |