- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.20 / $1,442.42 / $1,788.08
| Professional | | $1,104.20 | $1,442.42 | $1,788.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.51 / $1,461.07 / $2,107.23
| Professional | | $1,268.51 | $1,461.07 | $2,107.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.25 / $1,989.08 / $2,806.02
| Professional | | $1,360.25 | $1,989.08 | $2,806.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.53 / $1,681.10 / $2,954.25
| Professional | | $1,389.53 | $1,681.10 | $2,954.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.20 / $1,483.87 / $1,788.08
| Professional | | $1,104.20 | $1,483.87 | $1,788.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.88 / $2,063.10 / $2,679.46
| Professional | | $1,262.88 | $2,063.10 | $2,679.46 |