- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.57 / $1,590.91 / $1,938.97
| Professional | | $1,205.57 | $1,590.91 | $1,938.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.58 / $1,539.80 / $2,215.96
| Professional | | $1,332.58 | $1,539.80 | $2,215.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.39 / $2,198.37 / $3,145.39
| Professional | | $1,494.39 | $2,198.37 | $3,145.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.91 / $1,842.53 / $3,270.31
| Professional | | $1,469.91 | $1,842.53 | $3,270.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.57 / $1,590.91 / $1,938.97
| Professional | | $1,205.57 | $1,590.91 | $1,938.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.62 / $2,230.29 / $2,921.73
| Professional | | $1,473.62 | $2,230.29 | $2,921.73 |