- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.70 / $1,475.46 / $1,704.89
| Professional | | $1,224.70 | $1,475.46 | $1,704.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,437.34 / $1,860.08 / $2,635.69
| Professional | | $1,437.34 | $1,860.08 | $2,635.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.63 / $2,045.87 / $3,015.91
| Professional | | $1,416.63 | $2,045.87 | $3,015.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,721.35 / $1,991.60 / $3,055.22
| Professional | | $1,721.35 | $1,991.60 | $3,055.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.70 / $1,704.89 / $2,576.21
| Professional | | $1,224.70 | $1,704.89 | $2,576.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.57 / $1,821.62 / $2,767.99
| Professional | | $1,250.57 | $1,821.62 | $2,767.99 |