- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $2,570.40
| Professional | | $1,047.13 | $1,348.96 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $2,290.87
| Professional | | $1,023.29 | $1,621.81 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,479.11 / $2,511.89
| Professional | | $1,318.26 | $1,479.11 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $2,290.87
| Professional | | $1,258.93 | $1,548.82 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $3,235.94
| Professional | | $1,047.13 | $1,348.96 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,621.81 / $2,511.89
| Professional | | $1,174.90 | $1,621.81 | $2,511.89 |