- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.34 / $1,569.12 / $1,569.12
| Professional | | $1,105.34 | $1,569.12 | $1,569.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.74 / $1,700.49 / $2,456.32
| Professional | | $1,492.74 | $1,700.49 | $2,456.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.13 / $1,820.44 / $2,835.42
| Professional | | $1,378.13 | $1,820.44 | $2,835.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.51 / $1,838.51 / $2,820.37
| Professional | | $1,427.51 | $1,838.51 | $2,820.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.34 / $1,569.12 / $1,569.12
| Professional | | $1,105.34 | $1,569.12 | $1,569.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.23 / $1,765.14 / $2,591.31
| Professional | | $1,235.23 | $1,765.14 | $2,591.31 |