- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.95 / $1,973.53 / $1,973.53
| Professional | | $1,613.95 | $1,973.53 | $1,973.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,374.16 / $1,685.74 / $2,509.25
| Professional | | $1,374.16 | $1,685.74 | $2,509.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.16 / $1,973.53 / $2,756.48
| Professional | | $1,657.16 | $1,973.53 | $2,756.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.65 / $1,609.23 / $2,503.96
| Professional | | $1,445.65 | $1,609.23 | $2,503.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.95 / $1,973.53 / $1,973.53
| Professional | | $1,613.95 | $1,973.53 | $1,973.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.31 / $2,161.98 / $2,496.25
| Professional | | $1,530.31 | $2,161.98 | $2,496.25 |