- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,548.82 / $3,981.07
| Professional | | $1,174.90 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,318.26 / $1,621.81
| Professional | | $1,174.90 | $1,318.26 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $3,388.44
| Professional | | $1,288.25 | $1,905.46 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,818.38
| Professional | | $1,698.24 | $1,905.46 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,778.28 / $3,019.95
| Professional | | $1,148.15 | $1,778.28 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,995.26 / $2,398.83
| Professional | | $1,258.93 | $1,995.26 | $2,398.83 |