- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.05 / $1,459.37 / $1,771.78
| Professional | | $1,300.05 | $1,459.37 | $1,771.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.68 / $1,802.98 / $2,337.75
| Professional | | $1,486.68 | $1,802.98 | $2,337.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,506.05 / $1,962.21 / $3,255.09
| Professional | | $1,506.05 | $1,962.21 | $3,255.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.47 / $1,835.11 / $2,855.43
| Professional | | $1,502.47 | $1,835.11 | $2,855.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.05 / $1,459.37 / $1,771.78
| Professional | | $1,300.05 | $1,459.37 | $1,771.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.67 / $2,090.38 / $3,203.45
| Professional | | $1,486.67 | $2,090.38 | $3,203.45 |