- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $2,884.03
| Professional | | $1,202.26 | $1,513.56 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,905.46 / $2,570.40
| Professional | | $1,230.27 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $2,884.03
| Professional | | $1,513.56 | $1,778.28 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $2,630.27
| Professional | | $1,584.89 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,621.81 / $3,890.45
| Professional | | $1,380.38 | $1,621.81 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,754.23
| Professional | | $1,318.26 | $1,862.09 | $2,754.23 |