- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.96 / $1,643.70 / $1,917.02
| Professional | | $1,283.96 | $1,643.70 | $1,917.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.19 / $2,099.30 / $2,946.84
| Professional | | $1,622.19 | $2,099.30 | $2,946.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.15 / $2,290.11 / $3,367.19
| Professional | | $1,579.15 | $2,290.11 | $3,367.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,924.56 / $2,226.71 / $3,415.90
| Professional | | $1,924.56 | $2,226.71 | $3,415.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.96 / $1,557.87 / $1,917.02
| Professional | | $1,283.96 | $1,557.87 | $1,917.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.72 / $2,020.89 / $3,087.01
| Professional | | $1,393.72 | $2,020.89 | $3,087.01 |