- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.58 / $1,559.98 / $1,559.98
| Professional | | $1,146.58 | $1,559.98 | $1,559.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.54 / $1,680.56 / $2,392.10
| Professional | | $1,523.54 | $1,680.56 | $2,392.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.26 / $1,777.15 / $2,747.50
| Professional | | $1,429.26 | $1,777.15 | $2,747.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.22 / $1,791.78 / $2,748.68
| Professional | | $1,391.22 | $1,791.78 | $2,748.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.58 / $1,559.98 / $1,559.98
| Professional | | $1,146.58 | $1,559.98 | $1,559.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,321.26 / $1,828.11 / $2,516.48
| Professional | | $1,321.26 | $1,828.11 | $2,516.48 |