- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,089.03 / $1,376.45 / $2,195.21
| Professional | | $1,089.03 | $1,376.45 | $2,195.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.83 / $1,436.63 / $2,637.92
| Professional | | $1,058.83 | $1,436.63 | $2,637.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.42 / $2,008.84 / $2,976.68
| Professional | | $1,513.42 | $2,008.84 | $2,976.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.71 / $1,024.71 / $1,024.71
| Professional | | $1,024.71 | $1,024.71 | $1,024.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.60 / $1,045.43 / $1,926.96
| Professional | | $150.60 | $1,045.43 | $1,926.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.45 / $1,727.98 / $3,190.52
| Professional | | $1,224.45 | $1,727.98 | $3,190.52 |