- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.43 / $1,881.90 / $1,881.90
| Professional | | $1,332.43 | $1,881.90 | $1,881.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.50 / $1,608.88 / $2,376.61
| Professional | | $1,308.50 | $1,608.88 | $2,376.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.02 / $1,881.90 / $2,651.82
| Professional | | $1,465.02 | $1,881.90 | $2,651.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.74 / $1,535.86 / $2,389.80
| Professional | | $1,379.74 | $1,535.86 | $2,389.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.43 / $1,881.90 / $1,881.90
| Professional | | $1,332.43 | $1,881.90 | $1,881.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.57 / $1,771.58 / $2,138.12
| Professional | | $1,251.57 | $1,771.58 | $2,138.12 |