- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.30 / $1,238.30 / $1,315.72
| Professional | | $1,238.30 | $1,238.30 | $1,315.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.26 / $1,611.57 / $2,327.88
| Professional | | $1,355.26 | $1,611.57 | $2,327.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.55 / $1,737.63 / $2,634.01
| Professional | | $1,487.55 | $1,737.63 | $2,634.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.45 / $1,743.12 / $2,674.05
| Professional | | $1,353.45 | $1,743.12 | $2,674.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.30 / $1,238.30 / $1,315.72
| Professional | | $1,238.30 | $1,238.30 | $1,315.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.57 / $1,700.01 / $2,410.34
| Professional | | $1,412.57 | $1,700.01 | $2,410.34 |