- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,479.11 / $3,467.37
| Professional | | $1,174.90 | $1,479.11 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,905.46 / $2,754.23
| Professional | | $1,174.90 | $1,905.46 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,778.28 / $2,884.03
| Professional | | $1,412.54 | $1,778.28 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $3,311.31
| Professional | | $1,479.11 | $1,737.80 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $3,548.13
| Professional | | $1,230.27 | $1,778.28 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,621.81 / $2,754.23
| Professional | | $1,122.02 | $1,621.81 | $2,754.23 |