- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.68 / $1,219.55 / $1,532.74
| Professional | | $1,019.68 | $1,219.55 | $1,532.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.26 / $1,541.50 / $2,219.48
| Professional | | $1,027.26 | $1,541.50 | $2,219.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.19 / $1,405.61 / $1,839.29
| Professional | | $1,226.19 | $1,405.61 | $1,839.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.43 / $1,522.85 / $2,680.69
| Professional | | $1,187.43 | $1,522.85 | $2,680.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.58 / $1,538.33 / $2,901.36
| Professional | | $1,202.58 | $1,538.33 | $2,901.36 |