- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.34 / $1,161.64 / $1,161.64
| Professional | | $1,142.34 | $1,161.64 | $1,161.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,447.32 / $1,706.07 / $3,450.30
| Professional | | $1,447.32 | $1,706.07 | $3,450.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.90 / $1,655.78 / $2,162.39
| Professional | | $1,060.90 | $1,655.78 | $2,162.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.65 / $1,436.81 / $2,162.39
| Professional | | $1,003.65 | $1,436.81 | $2,162.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.60 / $1,336.05 / $2,174.27
| Professional | | $1,200.60 | $1,336.05 | $2,174.27 |