- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.07 / $1,496.32 / $1,496.32
| Professional | | $1,108.07 | $1,496.32 | $1,496.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.72 / $1,625.49 / $2,320.87
| Professional | | $1,477.72 | $1,625.49 | $2,320.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.14 / $1,839.74 / $2,592.73
| Professional | | $1,457.14 | $1,839.74 | $2,592.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.52 / $1,748.38 / $2,682.10
| Professional | | $1,357.52 | $1,748.38 | $2,682.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.07 / $1,496.32 / $1,496.32
| Professional | | $1,108.07 | $1,496.32 | $1,496.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.89 / $1,787.16 / $2,363.79
| Professional | | $1,367.89 | $1,787.16 | $2,363.79 |