- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.95 / $1,774.23 / $1,774.23
| Professional | | $1,306.95 | $1,774.23 | $1,774.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.68 / $1,518.21 / $2,247.07
| Professional | | $1,233.68 | $1,518.21 | $2,247.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.44 / $1,774.23 / $2,500.48
| Professional | | $1,458.44 | $1,774.23 | $2,500.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.97 / $1,449.30 / $2,255.11
| Professional | | $1,301.97 | $1,449.30 | $2,255.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.95 / $1,774.23 / $1,774.23
| Professional | | $1,306.95 | $1,774.23 | $1,774.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.48 / $1,722.24 / $2,268.81
| Professional | | $1,254.48 | $1,722.24 | $2,268.81 |