- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.82 / $1,368.34 / $1,622.20
| Professional | | $1,080.82 | $1,368.34 | $1,622.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.28 / $1,765.54 / $2,487.98
| Professional | | $1,364.28 | $1,765.54 | $2,487.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.86 / $1,946.64 / $2,810.35
| Professional | | $1,329.86 | $1,946.64 | $2,810.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.89 / $1,880.00 / $2,884.02
| Professional | | $1,624.89 | $1,880.00 | $2,884.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.82 / $1,426.93 / $1,622.20
| Professional | | $1,080.82 | $1,426.93 | $1,622.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.99 / $1,692.15 / $2,592.33
| Professional | | $1,112.99 | $1,692.15 | $2,592.33 |