- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.76 / $1,458.01 / $1,522.24
| Professional | | $1,035.76 | $1,458.01 | $1,522.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.08 / $1,694.12 / $2,574.79
| Professional | | $1,309.08 | $1,694.12 | $2,574.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,409.37 / $1,970.04 / $2,783.91
| Professional | | $1,409.37 | $1,970.04 | $2,783.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,619.53 / $1,873.80 / $2,874.50
| Professional | | $1,619.53 | $1,873.80 | $2,874.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.76 / $1,522.24 / $1,682.31
| Professional | | $1,035.76 | $1,522.24 | $1,682.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.66 / $1,873.80 / $2,874.50
| Professional | | $1,246.66 | $1,873.80 | $2,874.50 |