- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.10 / $1,395.10 / $2,296.50
| Professional | | $1,395.10 | $1,395.10 | $2,296.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.95 / $1,963.39 / $2,903.84
| Professional | | $1,591.95 | $1,963.39 | $2,903.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.57 / $2,296.50 / $3,220.02
| Professional | | $1,802.57 | $2,296.50 | $3,220.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.75 / $1,874.27 / $2,916.36
| Professional | | $1,683.75 | $1,874.27 | $2,916.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.10 / $1,604.37 / $2,296.50
| Professional | | $1,395.10 | $1,604.37 | $2,296.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,532.67 / $2,172.14 / $2,808.81
| Professional | | $1,532.67 | $2,172.14 | $2,808.81 |