- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.81 / $1,689.21 / $1,689.21
| Professional | | $1,307.81 | $1,689.21 | $1,689.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.19 / $1,445.23 / $2,143.17
| Professional | | $1,177.19 | $1,445.23 | $2,143.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.82 / $1,689.21 / $2,363.61
| Professional | | $1,424.82 | $1,689.21 | $2,363.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.39 / $1,379.63 / $2,146.69
| Professional | | $1,239.39 | $1,379.63 | $2,146.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.81 / $1,689.21 / $1,689.21
| Professional | | $1,307.81 | $1,689.21 | $1,689.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.80 / $1,622.52 / $1,958.22
| Professional | | $1,138.80 | $1,622.52 | $1,958.22 |