- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.24 / $1,195.24 / $1,430.59
| Professional | | $1,195.24 | $1,195.24 | $1,430.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.24 / $1,639.30 / $2,367.94
| Professional | | $1,377.24 | $1,639.30 | $2,367.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.09 / $1,762.36 / $2,714.10
| Professional | | $1,541.09 | $1,762.36 | $2,714.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,371.96 / $1,766.97 / $2,710.63
| Professional | | $1,371.96 | $1,766.97 | $2,710.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.24 / $1,195.24 / $1,430.59
| Professional | | $1,195.24 | $1,195.24 | $1,430.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,349.57 / $1,929.11 / $2,485.60
| Professional | | $1,349.57 | $1,929.11 | $2,485.60 |