- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.65 / $1,280.20 / $1,588.86
| Professional | | $1,093.65 | $1,280.20 | $1,588.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.33 / $1,658.19 / $2,336.52
| Professional | | $1,281.33 | $1,658.19 | $2,336.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.05 / $1,891.83 / $2,681.07
| Professional | | $1,240.05 | $1,891.83 | $2,681.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.96 / $1,765.54 / $2,708.43
| Professional | | $1,525.96 | $1,765.54 | $2,708.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.65 / $1,303.06 / $1,588.86
| Professional | | $1,093.65 | $1,303.06 | $1,588.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.00 / $1,713.03 / $2,215.13
| Professional | | $1,196.00 | $1,713.03 | $2,215.13 |