- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.18 / $2,057.48 / $2,057.48
| Professional | | $1,498.18 | $2,057.48 | $2,057.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.17 / $1,750.94 / $2,608.14
| Professional | | $1,428.17 | $1,750.94 | $2,608.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.24 / $2,057.48 / $2,890.20
| Professional | | $1,523.24 | $2,057.48 | $2,890.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.57 / $1,671.47 / $2,600.81
| Professional | | $1,501.57 | $1,671.47 | $2,600.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.18 / $2,057.48 / $2,057.48
| Professional | | $1,498.18 | $2,057.48 | $2,057.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.72 / $1,933.89 / $2,600.81
| Professional | | $1,260.72 | $1,933.89 | $2,600.81 |