- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.39 / $2,089.73 / $2,089.73
| Professional | | $1,533.39 | $2,089.73 | $2,089.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.53 / $1,795.42 / $2,635.01
| Professional | | $1,452.53 | $1,795.42 | $2,635.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.73 / $2,089.73 / $2,942.38
| Professional | | $1,719.73 | $2,089.73 | $2,942.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,539.71 / $1,713.93 / $2,666.88
| Professional | | $1,539.71 | $1,713.93 | $2,666.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.46 / $1,533.39 / $2,089.73
| Professional | | $1,443.46 | $1,533.39 | $2,089.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.36 / $1,971.20 / $2,379.04
| Professional | | $1,429.36 | $1,971.20 | $2,379.04 |