- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.89 / $1,462.89 / $1,763.28
| Professional | | $1,462.89 | $1,462.89 | $1,763.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,699.05 / $1,988.38 / $2,872.17
| Professional | | $1,699.05 | $1,988.38 | $2,872.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,843.95 / $2,142.55 / $3,279.12
| Professional | | $1,843.95 | $2,142.55 | $3,279.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.46 / $2,147.55 / $3,294.46
| Professional | | $1,667.46 | $2,147.55 | $3,294.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.89 / $1,462.89 / $1,763.28
| Professional | | $1,462.89 | $1,462.89 | $1,763.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.48 / $2,171.58 / $3,005.08
| Professional | | $1,543.48 | $2,171.58 | $3,005.08 |