- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.39 / $1,369.88 / $1,722.84
| Professional | | $1,219.39 | $1,369.88 | $1,722.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.08 / $1,999.52 / $3,063.01
| Professional | | $1,545.08 | $1,999.52 | $3,063.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,617.53 / $2,227.81 / $3,195.11
| Professional | | $1,617.53 | $2,227.81 | $3,195.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,926.62 / $2,229.10 / $3,419.56
| Professional | | $1,926.62 | $2,229.10 | $3,419.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,219.39 / $1,722.84 / $1,839.57
| Professional | | $1,219.39 | $1,722.84 | $1,839.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.12 / $1,849.75 / $2,967.75
| Professional | | $1,317.12 | $1,849.75 | $2,967.75 |