- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.76 / $1,411.76 / $2,766.48
| Professional | | $1,411.76 | $1,411.76 | $2,766.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,641.63 / $1,881.26 / $2,950.43
| Professional | | $1,641.63 | $1,881.26 | $2,950.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,767.21 / $2,110.12 / $3,023.12
| Professional | | $1,767.21 | $2,110.12 | $3,023.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,564.15 / $2,014.49 / $3,090.33
| Professional | | $1,564.15 | $2,014.49 | $3,090.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.76 / $1,411.76 / $2,766.48
| Professional | | $1,411.76 | $1,411.76 | $2,766.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.71 / $2,102.19 / $2,788.58
| Professional | | $1,467.71 | $2,102.19 | $2,788.58 |