- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.84 / $1,447.61 / $1,447.61
| Professional | | $1,055.84 | $1,447.61 | $1,447.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.34 / $1,605.85 / $2,319.61
| Professional | | $1,371.34 | $1,605.85 | $2,319.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.61 / $1,722.00 / $2,676.86
| Professional | | $1,323.61 | $1,722.00 | $2,676.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.60 / $1,727.86 / $2,650.64
| Professional | | $1,341.60 | $1,727.86 | $2,650.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.84 / $1,447.61 / $1,447.61
| Professional | | $1,055.84 | $1,447.61 | $1,447.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.24 / $1,782.10 / $2,650.64
| Professional | | $1,165.24 | $1,782.10 | $2,650.64 |