- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.98 / $1,452.60 / $1,762.84
| Professional | | $1,076.98 | $1,452.60 | $1,762.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.34 / $1,860.08 / $2,606.37
| Professional | | $1,437.34 | $1,860.08 | $2,606.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.03 / $2,089.65 / $2,974.33
| Professional | | $1,394.03 | $2,089.65 | $2,974.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.74 / $1,967.76 / $3,018.64
| Professional | | $1,700.74 | $1,967.76 | $3,018.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.98 / $1,584.01 / $1,762.84
| Professional | | $1,076.98 | $1,584.01 | $1,762.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.99 / $1,948.06 / $2,722.28
| Professional | | $1,202.99 | $1,948.06 | $2,722.28 |