- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.19 / $1,992.75 / $1,992.75
| Professional | | $1,493.19 | $1,992.75 | $1,992.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.10 / $1,716.40 / $2,516.09
| Professional | | $1,385.10 | $1,716.40 | $2,516.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.62 / $1,992.75 / $2,808.59
| Professional | | $1,638.62 | $1,992.75 | $2,808.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.94 / $1,638.50 / $2,549.51
| Professional | | $1,471.94 | $1,638.50 | $2,549.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.19 / $1,992.75 / $1,992.75
| Professional | | $1,493.19 | $1,992.75 | $1,992.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.97 / $1,879.37 / $2,430.23
| Professional | | $1,396.97 | $1,879.37 | $2,430.23 |