- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.57 / $1,729.87 / $2,081.27
| Professional | | $1,378.57 | $1,729.87 | $2,081.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,717.26 / $2,222.34 / $3,132.23
| Professional | | $1,717.26 | $2,222.34 | $3,132.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.23 / $2,493.94 / $3,560.28
| Professional | | $1,645.23 | $2,493.94 | $3,560.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.67 / $2,348.33 / $3,602.46
| Professional | | $2,029.67 | $2,348.33 | $3,602.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.57 / $1,944.84 / $2,081.27
| Professional | | $1,378.57 | $1,944.84 | $2,081.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,581.76 / $2,374.92 / $3,272.69
| Professional | | $1,581.76 | $2,374.92 | $3,272.69 |