- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $3,235.94
| Professional | | $1,096.48 | $1,380.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,819.70 / $2,630.27
| Professional | | $1,122.02 | $1,819.70 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,659.59 / $2,754.23
| Professional | | $1,318.26 | $1,659.59 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,659.59 / $3,162.28
| Professional | | $1,380.38 | $1,659.59 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,659.59 / $3,388.44
| Professional | | $1,174.90 | $1,659.59 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $2,570.40
| Professional | | $1,047.13 | $1,548.82 | $2,570.40 |