- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.91 / $1,431.51 / $1,853.92
| Professional | | $1,149.91 | $1,431.51 | $1,853.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.36 / $1,411.03 / $2,033.50
| Professional | | $1,199.36 | $1,411.03 | $2,033.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.85 / $1,593.67 / $2,272.62
| Professional | | $1,238.85 | $1,593.67 | $2,272.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.96 / $2,044.64 / $3,179.79
| Professional | | $1,437.96 | $2,044.64 | $3,179.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $832.00 / $1,564.18
| Professional | | $32.34 | $832.00 | $1,564.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,529.13 / $2,021.28 / $3,188.59
| Professional | | $1,529.13 | $2,021.28 | $3,188.59 |