- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.14 / $1,311.44 / $1,311.44
| Professional | | $1,258.14 | $1,311.44 | $1,311.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.66 / $1,456.74 / $2,229.46
| Professional | | $1,125.66 | $1,456.74 | $2,229.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.18 / $1,506.07 / $2,320.91
| Professional | | $924.18 | $1,506.07 | $2,320.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.25 / $1,612.94 / $2,389.46
| Professional | | $1,346.25 | $1,612.94 | $2,389.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.40 / $1,206.48 / $1,311.44
| Professional | | $1,111.40 | $1,206.48 | $1,311.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.48 / $1,518.90 / $2,138.51
| Professional | | $1,059.48 | $1,518.90 | $2,138.51 |