- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.57 / $1,293.89 / $1,638.47
| Professional | | $1,029.57 | $1,293.89 | $1,638.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.76 / $1,698.44 / $2,292.89
| Professional | | $1,110.76 | $1,698.44 | $2,292.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.65 / $1,472.52 / $2,007.98
| Professional | | $1,338.65 | $1,472.52 | $2,007.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.59 / $1,731.92 / $2,998.69
| Professional | | $1,254.59 | $1,731.92 | $2,998.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.24 / $1,685.50 / $2,973.75
| Professional | | $1,286.24 | $1,685.50 | $2,973.75 |