- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.92 / $1,418.61 / $1,603.15
| Professional | | $1,104.92 | $1,418.61 | $1,603.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.36 / $1,818.08 / $2,749.76
| Professional | | $1,545.36 | $1,818.08 | $2,749.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.92 / $2,073.59 / $2,927.22
| Professional | | $1,481.92 | $2,073.59 | $2,927.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.59 / $2,001.14 / $3,069.85
| Professional | | $1,729.59 | $2,001.14 | $3,069.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,104.92 / $1,603.15 / $1,973.33
| Professional | | $1,104.92 | $1,603.15 | $1,973.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,312.92 / $1,816.29 / $2,496.42
| Professional | | $1,312.92 | $1,816.29 | $2,496.42 |