- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.97 / $1,173.47 / $1,552.99
| Professional | | $1,023.97 | $1,173.47 | $1,552.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.67 / $1,518.86 / $2,160.01
| Professional | | $1,173.67 | $1,518.86 | $2,160.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.09 / $1,680.84 / $2,414.90
| Professional | | $1,148.09 | $1,680.84 | $2,414.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.01 / $1,626.75 / $2,495.53
| Professional | | $1,406.01 | $1,626.75 | $2,495.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.19 / $1,400.70 / $2,094.86
| Professional | | $941.19 | $1,400.70 | $2,094.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.53 / $1,536.60 / $2,243.98
| Professional | | $1,064.53 | $1,536.60 | $2,243.98 |