- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.91 / $1,784.45 / $2,217.23
| Professional | | $1,384.91 | $1,784.45 | $2,217.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.73 / $1,731.51 / $2,500.17
| Professional | | $1,519.73 | $1,731.51 | $2,500.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.67 / $2,500.51 / $3,640.50
| Professional | | $1,700.67 | $2,500.51 | $3,640.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.92 / $2,095.21 / $3,718.79
| Professional | | $1,652.92 | $2,095.21 | $3,718.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.91 / $1,794.14 / $2,217.23
| Professional | | $1,384.91 | $1,794.14 | $2,217.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,685.10 / $2,632.46 / $3,334.46
| Professional | | $1,685.10 | $2,632.46 | $3,334.46 |