- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.83 / $1,186.61 / $1,417.71
| Professional | | $1,031.83 | $1,186.61 | $1,417.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.36 / $1,535.30 / $2,165.09
| Professional | | $1,186.36 | $1,535.30 | $2,165.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.34 / $1,701.25 / $2,416.11
| Professional | | $1,146.34 | $1,701.25 | $2,416.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.43 / $1,635.34 / $2,508.69
| Professional | | $1,413.43 | $1,635.34 | $2,508.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.83 / $1,240.63 / $1,730.19
| Professional | | $1,031.83 | $1,240.63 | $1,730.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.25 / $1,595.29 / $2,223.56
| Professional | | $1,097.25 | $1,595.29 | $2,223.56 |