- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $3,235.94
| Professional | | $1,047.13 | $1,348.96 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,737.80 / $2,511.89
| Professional | | $1,122.02 | $1,737.80 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,737.80 / $2,630.27
| Professional | | $1,348.96 | $1,737.80 | $2,630.27 |
- 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
- $1,122.02 / $1,621.81 / $3,388.44
| Professional | | $1,122.02 | $1,621.81 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,479.11 / $2,511.89
| Professional | | $1,023.29 | $1,479.11 | $2,511.89 |