- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,548.82 / $3,630.78
| Professional | | $1,230.27 | $1,548.82 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,949.84 / $2,951.21
| Professional | | $1,230.27 | $1,949.84 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,949.84 / $3,019.95
| Professional | | $1,513.56 | $1,949.84 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $3,388.44
| Professional | | $1,513.56 | $1,819.70 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $4,073.80
| Professional | | $1,348.96 | $1,905.46 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,691.53
| Professional | | $1,202.26 | $1,778.28 | $2,691.53 |