- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $3,715.35
| Professional | | $1,122.02 | $1,548.82 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,995.26 / $2,951.21
| Professional | | $1,258.93 | $1,995.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $3,090.30
| Professional | | $1,412.54 | $1,905.46 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,862.09 / $3,548.13
| Professional | | $1,548.82 | $1,862.09 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $3,801.89
| Professional | | $1,258.93 | $1,862.09 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,819.70 / $3,019.95
| Professional | | $1,174.90 | $1,819.70 | $3,019.95 |