- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.73 / $1,104.73 / $1,793.82
| Professional | | $1,104.73 | $1,104.73 | $1,793.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.08 / $1,546.27 / $2,267.46
| Professional | | $1,247.08 | $1,546.27 | $2,267.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.30 / $1,793.82 / $2,530.19
| Professional | | $1,471.30 | $1,793.82 | $2,530.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.04 / $1,476.09 / $2,296.80
| Professional | | $1,326.04 | $1,476.09 | $2,296.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.73 / $1,272.17 / $1,793.82
| Professional | | $1,104.73 | $1,272.17 | $1,793.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.10 / $1,745.57 / $2,312.42
| Professional | | $1,212.10 | $1,745.57 | $2,312.42 |