- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $3,388.44
| Professional | | $1,122.02 | $1,380.38 | $3,388.44 |
- 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
- $1,380.38 / $1,737.80 / $2,754.23
| Professional | | $1,380.38 | $1,737.80 | $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 / $1,698.24 / $3,467.37
| Professional | | $1,174.90 | $1,698.24 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $2,454.71
| Professional | | $1,047.13 | $1,584.89 | $2,454.71 |