- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.61 / $1,397.70 / $1,397.70
| Professional | | $1,217.61 | $1,397.70 | $1,397.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.95 / $1,553.86 / $2,241.39
| Professional | | $1,327.95 | $1,553.86 | $2,241.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,347.41 / $1,718.49 / $2,587.02
| Professional | | $1,347.41 | $1,718.49 | $2,587.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.79 / $1,670.15 / $2,562.10
| Professional | | $1,296.79 | $1,670.15 | $2,562.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.61 / $1,397.70 / $1,397.70
| Professional | | $1,217.61 | $1,397.70 | $1,397.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.52 / $1,999.48 / $2,413.16
| Professional | | $1,443.52 | $1,999.48 | $2,413.16 |