- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.01 / $1,336.63 / $1,622.01
| Professional | | $1,058.01 | $1,336.63 | $1,622.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.56 / $1,725.79 / $2,436.88
| Professional | | $1,333.56 | $1,725.79 | $2,436.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.79 / $1,946.41 / $2,750.51
| Professional | | $1,296.79 | $1,946.41 | $2,750.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.50 / $1,841.37 / $2,824.75
| Professional | | $1,591.50 | $1,841.37 | $2,824.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.01 / $1,474.51 / $1,622.01
| Professional | | $1,058.01 | $1,474.51 | $1,622.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,110.90 / $1,631.87 / $2,532.33
| Professional | | $1,110.90 | $1,631.87 | $2,532.33 |