- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.27 / $1,494.43 / $1,494.43
| Professional | | $1,170.27 | $1,494.43 | $1,494.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.49 / $1,659.49 / $2,389.54
| Professional | | $1,423.49 | $1,659.49 | $2,389.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.37 / $1,837.41 / $2,756.73
| Professional | | $1,391.37 | $1,837.41 | $2,756.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.07 / $1,781.28 / $2,732.58
| Professional | | $1,383.07 | $1,781.28 | $2,732.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.27 / $1,494.43 / $1,494.43
| Professional | | $1,170.27 | $1,494.43 | $1,494.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.07 / $2,130.31 / $2,571.07
| Professional | | $1,383.07 | $2,130.31 | $2,571.07 |