- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.85 / $1,638.06 / $1,805.75
| Professional | | $1,412.85 | $1,638.06 | $1,805.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.83 / $1,457.59 / $1,851.14
| Professional | | $1,311.83 | $1,457.59 | $1,851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.78 / $1,605.87 / $3,404.15
| Professional | | $1,172.78 | $1,605.87 | $3,404.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.99 / $1,778.32 / $2,949.65
| Professional | | $1,350.99 | $1,778.32 | $2,949.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,088.76 / $1,486.55 / $2,539.77
| Professional | | $1,088.76 | $1,486.55 | $2,539.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.05 / $1,053.05 / $1,932.05
| Professional | | $1,053.05 | $1,053.05 | $1,932.05 |