- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.65 / $1,936.12 / $1,936.12
| Professional | | $1,419.65 | $1,936.12 | $1,936.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.28 / $1,666.74 / $2,445.51
| Professional | | $1,346.28 | $1,666.74 | $2,445.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,499.37 / $1,936.12 / $2,730.04
| Professional | | $1,499.37 | $1,936.12 | $2,730.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.36 / $1,591.09 / $2,475.73
| Professional | | $1,429.36 | $1,591.09 | $2,475.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.65 / $1,936.12 / $1,936.12
| Professional | | $1,419.65 | $1,936.12 | $1,936.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.15 / $1,825.46 / $2,492.21
| Professional | | $1,292.15 | $1,825.46 | $2,492.21 |