- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.32 / $1,625.53 / $1,625.53
| Professional | | $1,096.32 | $1,625.53 | $1,625.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.72 / $1,734.11 / $2,565.05
| Professional | | $1,409.72 | $1,734.11 | $2,565.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,515.82 / $1,888.41 / $2,982.82
| Professional | | $1,515.82 | $1,888.41 | $2,982.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.12 / $1,915.30 / $2,938.17
| Professional | | $1,487.12 | $1,915.30 | $2,938.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.32 / $1,625.53 / $1,625.53
| Professional | | $1,096.32 | $1,625.53 | $1,625.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.20 / $1,542.92 / $2,705.28
| Professional | | $1,401.20 | $1,542.92 | $2,705.28 |