- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.80 / $1,528.72 / $1,784.59
| Professional | | $1,195.80 | $1,528.72 | $1,784.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.49 / $1,952.17 / $2,733.51
| Professional | | $1,508.49 | $1,952.17 | $2,733.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.50 / $2,123.39 / $3,133.79
| Professional | | $1,463.50 | $2,123.39 | $3,133.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,785.24 / $2,065.52 / $3,168.62
| Professional | | $1,785.24 | $2,065.52 | $3,168.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.80 / $1,447.50 / $1,784.59
| Professional | | $1,195.80 | $1,447.50 | $1,784.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.19 / $1,856.28 / $2,400.36
| Professional | | $1,280.19 | $1,856.28 | $2,400.36 |