- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.39 / $1,509.42 / $1,887.76
| Professional | | $1,160.39 | $1,509.42 | $1,887.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.30 / $1,471.57 / $2,117.39
| Professional | | $1,262.30 | $1,471.57 | $2,117.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.43 / $2,102.36 / $3,067.91
| Professional | | $1,414.43 | $2,102.36 | $3,067.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.78 / $1,816.98 / $3,224.96
| Professional | | $1,404.78 | $1,816.98 | $3,224.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.09 / $1,509.42 / $1,887.76
| Professional | | $1,177.09 | $1,509.42 | $1,887.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,434.70 / $2,170.88 / $3,015.11
| Professional | | $1,434.70 | $2,170.88 | $3,015.11 |