- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.57 / $1,623.45 / $2,616.08
| Professional | | $1,318.57 | $1,623.45 | $2,616.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.33 / $1,805.45 / $2,063.64
| Professional | | $1,629.33 | $1,805.45 | $2,063.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.47 / $1,699.47 / $3,472.30
| Professional | | $1,290.47 | $1,699.47 | $3,472.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.70 / $1,812.06 / $3,010.86
| Professional | | $1,404.70 | $1,812.06 | $3,010.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.18 / $1,649.08 / $2,994.18
| Professional | | $1,147.18 | $1,649.08 | $2,994.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.68 / $1,116.68 / $1,975.34
| Professional | | $1,116.68 | $1,116.68 | $1,975.34 |