- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.96 / $1,193.96 / $1,423.69
| Professional | | $1,193.96 | $1,193.96 | $1,423.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,368.66 / $1,644.03 / $2,407.34
| Professional | | $1,368.66 | $1,644.03 | $2,407.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.94 / $1,782.64 / $2,793.58
| Professional | | $1,508.94 | $1,782.64 | $2,793.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,397.88 / $1,800.36 / $2,761.85
| Professional | | $1,397.88 | $1,800.36 | $2,761.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.96 / $1,193.96 / $1,423.69
| Professional | | $1,193.96 | $1,193.96 | $1,423.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.21 / $1,758.87 / $2,542.27
| Professional | | $1,419.21 | $1,758.87 | $2,542.27 |