- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.72 / $1,621.64 / $2,060.10
| Professional | | $1,246.72 | $1,621.64 | $2,060.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.65 / $1,596.06 / $2,264.29
| Professional | | $1,356.65 | $1,596.06 | $2,264.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.04 / $2,259.23 / $3,296.49
| Professional | | $1,520.04 | $2,259.23 | $3,296.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.76 / $1,962.07 / $3,482.48
| Professional | | $1,498.76 | $1,962.07 | $3,482.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.71 / $1,621.64 / $2,060.10
| Professional | | $1,281.71 | $1,621.64 | $2,060.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.43 / $2,377.17 / $3,127.52
| Professional | | $1,575.43 | $2,377.17 | $3,127.52 |