- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.42 / $1,338.86 / $1,616.03
| Professional | | $1,070.42 | $1,338.86 | $1,616.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.04 / $1,736.76 / $2,465.91
| Professional | | $1,342.04 | $1,736.76 | $2,465.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.63 / $1,939.23 / $2,758.35
| Professional | | $1,313.63 | $1,939.23 | $2,758.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.47 / $1,863.31 / $2,858.42
| Professional | | $1,610.47 | $1,863.31 | $2,858.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.42 / $1,466.40 / $1,616.03
| Professional | | $1,070.42 | $1,466.40 | $1,616.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.90 / $1,699.59 / $2,556.08
| Professional | | $1,098.90 | $1,699.59 | $2,556.08 |