- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.92 / $1,401.42 / $1,800.11
| Professional | | $1,077.92 | $1,401.42 | $1,800.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.21 / $1,379.08 / $1,957.17
| Professional | | $1,172.21 | $1,379.08 | $1,957.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.63 / $1,952.52 / $2,849.96
| Professional | | $1,312.63 | $1,952.52 | $2,849.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.78 / $1,720.52 / $3,053.75
| Professional | | $1,296.78 | $1,720.52 | $3,053.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.45 / $1,401.42 / $1,800.11
| Professional | | $1,121.45 | $1,401.42 | $1,800.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.78 / $2,062.96 / $2,815.05
| Professional | | $1,296.78 | $2,062.96 | $2,815.05 |