- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $2,511.89
| Professional | | $1,348.96 | $1,659.59 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,137.96 / $3,162.28
| Professional | | $1,318.26 | $2,137.96 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,041.74 / $3,235.94
| Professional | | $1,258.93 | $2,041.74 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $3,715.35
| Professional | | $1,659.59 | $1,949.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $3,981.07
| Professional | | $1,348.96 | $1,995.26 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $3,162.28
| Professional | | $1,258.93 | $1,905.46 | $3,162.28 |