- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.83 / $1,549.36 / $2,871.79
| Professional | | $1,421.83 | $1,549.36 | $2,871.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.15 / $1,620.98 / $1,852.78
| Professional | | $1,361.15 | $1,620.98 | $1,852.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.40 / $1,592.00 / $3,190.78
| Professional | | $1,188.40 | $1,592.00 | $3,190.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.07 / $1,682.25 / $2,759.67
| Professional | | $1,304.07 | $1,682.25 | $2,759.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.04 / $1,517.62 / $2,447.27
| Professional | | $1,117.04 | $1,517.62 | $2,447.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.25 / $1,039.25 / $1,826.69
| Professional | | $1,039.25 | $1,039.25 | $1,826.69 |