- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,318.26 / $3,467.37
| Professional | | $1,148.15 | $1,318.26 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,862.09 / $2,754.23
| Professional | | $1,174.90 | $1,862.09 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $2,818.38
| Professional | | $1,412.54 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $3,311.31
| Professional | | $1,445.44 | $1,737.80 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,584.89 / $3,548.13
| Professional | | $1,202.26 | $1,584.89 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $2,691.53
| Professional | | $1,096.48 | $1,621.81 | $2,691.53 |