- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.58 / $1,732.10 / $1,915.50
| Professional | | $1,266.58 | $1,732.10 | $1,915.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,694.12 / $1,839.67 / $2,340.00
| Professional | | $1,694.12 | $1,839.67 | $2,340.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.76 / $1,723.33 / $3,585.75
| Professional | | $1,334.76 | $1,723.33 | $3,585.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.05 / $1,880.88 / $3,113.84
| Professional | | $1,458.05 | $1,880.88 | $3,113.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.44 / $1,674.75 / $3,351.74
| Professional | | $1,220.44 | $1,674.75 | $3,351.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.48 / $1,142.48 / $2,045.93
| Professional | | $1,142.48 | $1,142.48 | $2,045.93 |