- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.60 / $1,472.67 / $5,559.88
| Professional | | $1,419.60 | $1,472.67 | $5,559.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.41 / $1,603.18 / $1,832.43
| Professional | | $1,601.41 | $1,603.18 | $1,832.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.85 / $1,861.06 / $4,311.91
| Professional | | $1,350.85 | $1,861.06 | $4,311.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.51 / $1,899.92 / $3,038.20
| Professional | | $1,428.51 | $1,899.92 | $3,038.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,210.71 / $1,656.01 / $3,196.93
| Professional | | $1,210.71 | $1,656.01 | $3,196.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.35 / $1,642.79 / $2,043.63
| Professional | | $1,113.35 | $1,642.79 | $2,043.63 |