- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.86 / $1,185.86 / $2,046.74
| Professional | | $1,185.86 | $1,185.86 | $2,046.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.23 / $1,579.67 / $2,485.92
| Professional | | $1,378.23 | $1,579.67 | $2,485.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,484.31 / $1,774.75 / $2,542.64
| Professional | | $1,484.31 | $1,774.75 | $2,542.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.90 / $1,697.34 / $2,603.81
| Professional | | $1,317.90 | $1,697.34 | $2,603.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.86 / $1,185.86 / $2,046.74
| Professional | | $1,185.86 | $1,185.86 | $2,046.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.83 / $1,881.66 / $2,352.08
| Professional | | $1,393.83 | $1,881.66 | $2,352.08 |