- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.71 / $1,453.51 / $1,453.51
| Professional | | $1,259.71 | $1,453.51 | $1,453.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.41 / $1,744.21 / $1,988.40
| Professional | | $1,550.41 | $1,744.21 | $1,988.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.15 / $1,027.15 / $1,027.15
| Professional | | $1,027.15 | $1,027.15 | $1,027.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.01 / $2,325.61 / $2,907.02
| Professional | | $1,938.01 | $2,325.61 | $2,907.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.96 / $872.10 / $1,453.51
| Professional | | $813.96 | $872.10 | $1,453.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.01 / $969.01 / $969.01
| Professional | | $969.01 | $969.01 | $969.01 |