- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.49 / $1,121.49 / $1,341.04
| Professional | | $1,121.49 | $1,121.49 | $1,341.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.25 / $1,538.06 / $2,221.69
| Professional | | $1,294.25 | $1,538.06 | $2,221.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.28 / $1,654.27 / $2,543.67
| Professional | | $1,436.28 | $1,654.27 | $2,543.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,287.90 / $1,658.71 / $2,544.55
| Professional | | $1,287.90 | $1,658.71 | $2,544.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.49 / $1,121.49 / $1,341.04
| Professional | | $1,121.49 | $1,121.49 | $1,341.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.43 / $1,679.57 / $2,330.82
| Professional | | $1,182.43 | $1,679.57 | $2,330.82 |