- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.78 / $1,165.78 / $1,388.32
| Professional | | $1,165.78 | $1,165.78 | $1,388.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.55 / $1,604.26 / $2,352.02
| Professional | | $1,335.55 | $1,604.26 | $2,352.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.08 / $1,741.31 / $2,731.75
| Professional | | $1,470.08 | $1,741.31 | $2,731.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.41 / $1,759.82 / $2,699.66
| Professional | | $1,366.41 | $1,759.82 | $2,699.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.78 / $1,165.78 / $1,388.32
| Professional | | $1,165.78 | $1,165.78 | $1,388.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.65 / $1,759.82 / $2,485.11
| Professional | | $1,224.65 | $1,759.82 | $2,485.11 |