- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,778.28 / $2,344.23
| Professional | | $1,047.13 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $2,884.03
| Professional | | $1,258.93 | $1,905.46 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $2,884.03
| Professional | | $1,698.24 | $2,089.30 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,862.09 / $2,454.71
| Professional | | $1,548.82 | $1,862.09 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $2,344.23
| Professional | | $1,513.56 | $1,819.70 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,238.72 / $2,754.23
| Professional | | $1,584.89 | $2,238.72 | $2,754.23 |