- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.63 / $1,792.56 / $1,995.30
| Professional | | $1,645.63 | $1,792.56 | $1,995.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.07 / $1,584.07 / $2,011.77
| Professional | | $1,584.07 | $1,584.07 | $2,011.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.30 / $1,797.66 / $3,693.04
| Professional | | $1,374.30 | $1,797.66 | $3,693.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.34 / $1,944.47 / $3,195.98
| Professional | | $1,507.34 | $1,944.47 | $3,195.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.24 / $1,717.76 / $3,021.53
| Professional | | $1,291.24 | $1,717.76 | $3,021.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.44 / $1,733.44 / $2,111.92
| Professional | | $1,733.44 | $1,733.44 | $2,111.92 |