- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.53 / $1,566.36 / $2,109.40
| Professional | | $1,140.53 | $1,566.36 | $2,109.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,656.06 / $1,876.52 / $2,771.39
| Professional | | $1,656.06 | $1,876.52 | $2,771.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.67 / $1,924.94 / $2,890.77
| Professional | | $919.67 | $1,924.94 | $2,890.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,566.00 / $2,016.87 / $3,093.99
| Professional | | $1,566.00 | $2,016.87 | $3,093.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.53 / $1,566.36 / $2,039.13
| Professional | | $1,140.53 | $1,566.36 | $2,039.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.85 / $1,978.07 / $2,682.15
| Professional | | $1,359.85 | $1,978.07 | $2,682.15 |