- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,617.65 / $1,761.79 / $3,557.66
| Professional | | $1,617.65 | $1,761.79 | $3,557.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.08 / $1,647.36 / $1,960.97
| Professional | | $1,632.08 | $1,647.36 | $1,960.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.56 / $1,762.96 / $3,648.23
| Professional | | $1,353.56 | $1,762.96 | $3,648.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.42 / $1,900.71 / $3,159.55
| Professional | | $1,473.42 | $1,900.71 | $3,159.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.18 / $1,621.77 / $2,743.64
| Professional | | $1,219.18 | $1,621.77 | $2,743.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.60 / $1,109.60 / $2,072.02
| Professional | | $1,109.60 | $1,109.60 | $2,072.02 |