- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.47 / $1,773.44 / $3,025.68
| Professional | | $1,633.47 | $1,773.44 | $3,025.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,727.91 / $1,924.08 / $2,199.21
| Professional | | $1,727.91 | $1,924.08 | $2,199.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,295.64 / $1,737.78 / $3,684.20
| Professional | | $1,295.64 | $1,737.78 | $3,684.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,489.86 / $1,921.92 / $3,193.03
| Professional | | $1,489.86 | $1,921.92 | $3,193.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.46 / $1,641.03 / $3,338.56
| Professional | | $1,205.46 | $1,641.03 | $3,338.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.88 / $1,181.88 / $2,095.02
| Professional | | $1,181.88 | $1,181.88 | $2,095.02 |