- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.81 / $1,318.50 / $1,482.20
| Professional | | $1,008.81 | $1,318.50 | $1,482.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.40 / $1,638.87 / $2,510.57
| Professional | | $1,266.40 | $1,638.87 | $2,510.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.14 / $1,921.32 / $2,712.37
| Professional | | $1,373.14 | $1,921.32 | $2,712.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.14 / $1,827.06 / $2,802.82
| Professional | | $1,579.14 | $1,827.06 | $2,802.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.81 / $1,482.20 / $1,830.63
| Professional | | $1,008.81 | $1,482.20 | $1,830.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.86 / $1,750.05 / $2,499.61
| Professional | | $1,213.86 | $1,750.05 | $2,499.61 |