- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.73 / $1,381.15 / $1,723.90
| Professional | | $1,016.73 | $1,381.15 | $1,723.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.91 / $1,502.50 / $2,154.91
| Professional | | $1,365.91 | $1,502.50 | $2,154.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.59 / $1,698.14 / $2,405.63
| Professional | | $1,239.59 | $1,698.14 | $2,405.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.24 / $1,624.37 / $2,491.87
| Professional | | $1,261.24 | $1,624.37 | $2,491.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.73 / $1,381.15 / $1,381.15
| Professional | | $1,016.73 | $1,381.15 | $1,381.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.90 / $1,645.22 / $2,202.55
| Professional | | $1,128.90 | $1,645.22 | $2,202.55 |