- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.57 / $1,851.13 / $1,852.67
| Professional | | $1,219.57 | $1,851.13 | $1,852.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.97 / $1,593.34 / $2,335.50
| Professional | | $1,286.97 | $1,593.34 | $2,335.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,522.77 / $1,851.13 / $2,609.23
| Professional | | $1,522.77 | $1,851.13 | $2,609.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.41 / $1,521.02 / $2,366.71
| Professional | | $1,366.41 | $1,521.02 | $2,366.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.57 / $1,389.17 / $1,851.13
| Professional | | $1,219.57 | $1,389.17 | $1,851.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.66 / $1,745.55 / $2,379.58
| Professional | | $1,266.66 | $1,745.55 | $2,379.58 |