- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.95 / $1,898.13 / $1,898.13
| Professional | | $1,316.95 | $1,898.13 | $1,898.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.32 / $1,611.48 / $2,355.21
| Professional | | $1,293.32 | $1,611.48 | $2,355.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.98 / $1,898.13 / $2,651.27
| Professional | | $1,498.98 | $1,898.13 | $2,651.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.96 / $1,538.33 / $2,393.64
| Professional | | $1,381.96 | $1,538.33 | $2,393.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.95 / $1,898.13 / $1,898.13
| Professional | | $1,316.95 | $1,898.13 | $1,898.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.99 / $1,734.53 / $2,393.64
| Professional | | $1,244.99 | $1,734.53 | $2,393.64 |