- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.66 / $1,967.50 / $1,967.50
| Professional | | $1,420.66 | $1,967.50 | $1,967.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.45 / $1,693.94 / $2,484.29
| Professional | | $1,367.45 | $1,693.94 | $2,484.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.44 / $1,967.50 / $2,772.82
| Professional | | $1,551.44 | $1,967.50 | $2,772.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.69 / $1,617.06 / $2,516.15
| Professional | | $1,452.69 | $1,617.06 | $2,516.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.66 / $1,967.50 / $1,967.50
| Professional | | $1,420.66 | $1,967.50 | $1,967.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.73 / $1,854.81 / $2,398.46
| Professional | | $1,312.73 | $1,854.81 | $2,398.46 |