- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.92 / $1,841.87 / $1,841.87
| Professional | | $1,413.92 | $1,841.87 | $1,841.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.33 / $1,570.02 / $2,345.46
| Professional | | $1,281.33 | $1,570.02 | $2,345.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.88 / $1,841.87 / $2,569.42
| Professional | | $1,548.88 | $1,841.87 | $2,569.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.41 / $1,498.76 / $2,332.07
| Professional | | $1,346.41 | $1,498.76 | $2,332.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.92 / $1,841.87 / $1,841.87
| Professional | | $1,413.92 | $1,841.87 | $1,841.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.95 / $1,773.07 / $2,139.92
| Professional | | $1,335.95 | $1,773.07 | $2,139.92 |