- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.91 / $1,720.35 / $2,640.33
| Professional | | $1,090.91 | $1,720.35 | $2,640.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.74 / $1,832.12 / $2,708.75
| Professional | | $1,492.74 | $1,832.12 | $2,708.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,535.97 / $1,995.07 / $3,143.72
| Professional | | $1,535.97 | $1,995.07 | $3,143.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.18 / $2,023.55 / $3,104.23
| Professional | | $1,571.18 | $2,023.55 | $3,104.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.97 / $1,720.35 / $2,640.33
| Professional | | $1,324.97 | $1,720.35 | $2,640.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.97 / $1,814.50 / $2,853.51
| Professional | | $1,211.97 | $1,814.50 | $2,853.51 |