- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.98 / $1,985.70 / $1,985.70
| Professional | | $1,473.98 | $1,985.70 | $1,985.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.22 / $1,684.02 / $2,528.73
| Professional | | $1,375.22 | $1,684.02 | $2,528.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.07 / $1,985.70 / $2,777.40
| Professional | | $1,635.07 | $1,985.70 | $2,777.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,444.17 / $1,607.58 / $2,501.39
| Professional | | $1,444.17 | $1,607.58 | $2,501.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.98 / $1,985.70 / $1,985.70
| Professional | | $1,473.98 | $1,985.70 | $1,985.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,324.47 / $1,882.46 / $2,434.21
| Professional | | $1,324.47 | $1,882.46 | $2,434.21 |