- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.07 / $1,992.26 / $1,992.26
| Professional | | $1,484.07 | $1,992.26 | $1,992.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.28 / $1,703.88 / $2,510.17
| Professional | | $1,382.28 | $1,703.88 | $2,510.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.10 / $1,992.26 / $2,798.84
| Professional | | $1,639.10 | $1,992.26 | $2,798.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,461.20 / $1,626.54 / $2,530.90
| Professional | | $1,461.20 | $1,626.54 | $2,530.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.07 / $1,992.26 / $1,992.26
| Professional | | $1,484.07 | $1,992.26 | $1,992.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.03 / $1,878.04 / $2,530.90
| Professional | | $1,449.03 | $1,878.04 | $2,530.90 |