- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.57 / $1,620.80 / $1,630.33
| Professional | | $1,071.57 | $1,620.80 | $1,630.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.08 / $1,398.16 / $2,050.00
| Professional | | $1,127.08 | $1,398.16 | $2,050.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,333.05 / $1,620.81 / $2,287.35
| Professional | | $1,333.05 | $1,620.81 | $2,287.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,199.03 / $1,334.70 / $2,076.79
| Professional | | $1,199.03 | $1,334.70 | $2,076.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.57 / $1,620.80 / $1,951.95
| Professional | | $1,071.57 | $1,620.80 | $1,951.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.44 / $1,526.72 / $1,974.21
| Professional | | $1,111.44 | $1,526.72 | $1,974.21 |