- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.66 / $1,193.51 / $1,329.10
| Professional | | $1,068.66 | $1,193.51 | $1,329.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.07 / $1,239.46 / $1,416.70
| Professional | | $1,159.07 | $1,239.46 | $1,416.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.88 / $1,193.16 / $2,445.10
| Professional | | $916.88 | $1,193.16 | $2,445.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.85 / $1,230.13 / $1,498.55
| Professional | | $973.85 | $1,230.13 | $1,498.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.68 / $1,102.64 / $2,001.55
| Professional | | $861.68 | $1,102.64 | $2,001.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.25 / $846.25 / $1,404.53
| Professional | | $846.25 | $846.25 | $1,404.53 |