- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $3,019.95
| Professional | | $1,096.48 | $1,584.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,949.84 / $2,570.40
| Professional | | $977.24 | $1,949.84 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $3,019.95
| Professional | | $1,380.38 | $1,737.80 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $2,691.53
| Professional | | $1,584.89 | $1,905.46 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $3,630.78
| Professional | | $1,348.96 | $1,621.81 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,698.24 / $2,951.21
| Professional | | $1,174.90 | $1,698.24 | $2,951.21 |