- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,445.44 / $1,905.46
| Professional | | $1,047.13 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,862.09 / $2,691.53
| Professional | | $1,148.15 | $1,862.09 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,548.82 / $2,818.38
| Professional | | $724.44 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $3,235.94
| Professional | | $1,412.54 | $1,698.24 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $3,467.37
| Professional | | $1,047.13 | $1,584.89 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $2,691.53
| Professional | | $1,023.29 | $1,621.81 | $2,691.53 |