- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $4,265.80
| Professional | | $1,445.44 | $1,819.70 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,290.87 / $3,388.44
| Professional | | $1,412.54 | $2,290.87 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,344.23 / $3,548.13
| Professional | | $1,778.28 | $2,344.23 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,137.96 / $3,981.07
| Professional | | $1,778.28 | $2,137.96 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $4,570.88
| Professional | | $1,584.89 | $2,290.87 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $3,162.28
| Professional | | $1,412.54 | $2,089.30 | $3,162.28 |