- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $3,162.28
| Professional | | $1,348.96 | $1,698.24 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,137.96 / $2,818.38
| Professional | | $1,348.96 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $3,162.28
| Professional | | $1,659.59 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $2,951.21
| Professional | | $1,737.80 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $4,265.80
| Professional | | $1,348.96 | $1,995.26 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $3,090.30
| Professional | | $1,445.44 | $2,041.74 | $3,090.30 |