- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,495.22 / $1,626.80 / $2,707.98
| Professional | | $1,495.22 | $1,626.80 | $2,707.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.86 / $1,747.97 / $1,997.94
| Professional | | $1,460.86 | $1,747.97 | $1,997.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.78 / $1,650.80 / $3,348.60
| Professional | | $1,243.78 | $1,650.80 | $3,348.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.82 / $1,749.01 / $2,891.68
| Professional | | $1,355.82 | $1,749.01 | $2,891.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.45 / $1,578.92 / $2,917.24
| Professional | | $1,166.45 | $1,578.92 | $2,917.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.78 / $1,081.78 / $1,905.74
| Professional | | $1,081.78 | $1,081.78 | $1,905.74 |