- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.26 / $1,572.89 / $1,572.89
| Professional | | $1,170.26 | $1,572.89 | $1,572.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.59 / $1,370.96 / $2,011.21
| Professional | | $1,094.59 | $1,370.96 | $2,011.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.23 / $1,572.89 / $2,220.42
| Professional | | $1,250.23 | $1,572.89 | $2,220.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.70 / $1,308.74 / $2,036.40
| Professional | | $1,175.70 | $1,308.74 | $2,036.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,106.68 / $1,538.17 / $1,572.89
| Professional | | $1,106.68 | $1,538.17 | $1,572.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.52 / $1,490.27 / $2,048.08
| Professional | | $1,053.52 | $1,490.27 | $2,048.08 |