- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.54 / $1,524.32 / $1,855.47
| Professional | | $1,225.54 | $1,524.32 | $1,855.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.11 / $1,986.62 / $2,807.99
| Professional | | $1,535.11 | $1,986.62 | $2,807.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.80 / $2,172.15 / $3,148.88
| Professional | | $1,408.80 | $2,172.15 | $3,148.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,833.88 / $2,121.80 / $3,254.95
| Professional | | $1,833.88 | $2,121.80 | $3,254.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.54 / $1,627.65 / $1,855.47
| Professional | | $1,225.54 | $1,627.65 | $1,855.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.70 / $2,063.02 / $3,165.00
| Professional | | $1,277.70 | $2,063.02 | $3,165.00 |