- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.24 / $1,375.98 / $1,608.22
| Professional | | $1,094.24 | $1,375.98 | $1,608.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.27 / $1,765.53 / $2,722.90
| Professional | | $1,364.27 | $1,765.53 | $2,722.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.78 / $2,083.51 / $2,940.78
| Professional | | $1,488.78 | $2,083.51 | $2,940.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.69 / $1,981.58 / $3,039.85
| Professional | | $1,712.69 | $1,981.58 | $3,039.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.24 / $1,608.22 / $2,044.08
| Professional | | $1,094.24 | $1,608.22 | $2,044.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.08 / $1,958.65 / $2,720.34
| Professional | | $1,317.08 | $1,958.65 | $2,720.34 |